Missteps marked vaccine rollout
Experts: Early expansion of eligibility, planning shortfalls among the state’s problems
Vickie Shepherd showed up for a COVID19 vaccination appointment, only to be turned away when she got there. She booked another, then canceled it because she didn’t want to drive in the dark. But finally, Shepherd found a time slot that stuck.
Now the 68-year-old Waldorf woman said she is waiting for more information about her second dose appointment, which she said wasn’t scheduled at the vaccination clinic last month.
“Now I’m in a pickle, because I don’t know what’s going to happen,” Shepherd said. “It’s too much drama.”
Shepherd and scores of other Marylanders say they have found themselves trapped in cycles of dead ends and loose threads since Jan. 25, when more than 2 million state residents became eligible for COVID19 vaccination appointments at once. The process of securing a time slot has been ruthless, fraught and confusing, particularly for those without computer skills or internet connection.
After mingling early on among the states that rolled out their vaccines least efficiently, Maryland now finds itself in the middle. As of Friday, Maryland ranked 23rd of 50 states and Washington, D.C., for the percentage of adults who have been completely immunized, according to U.S. Centers for Disease Control and Prevention data.
Over 2.8 million vaccine doses have been administered here, with about 1 million people having completed their regimens — about 17% of the state’s more than 6 million people, according to state health department data.
Republican Gov. Larry Hogan says the state will double the number of mass clinics by the end of April and make all adults eligible to be vaccinated by May. His administration cites limited national vaccine inventory as the main culprit behind the cutthroat nature of vaccine access, and points to new
data showing Maryland starting to outpace states such as West Virginia, cited early on as a more efficient vaccinator.
But lawmakers, public health and technology experts say the early expansion of eligibility marked just one of a handful of missteps that made Maryland’s vaccination rollout inefficient and inequitable. Technological oversights and snafus, coupled with decentralization, planning shortfalls and limited coordination among government agencies, all contributed to the early problems — some of which still persist.
Surprising the locals
Hogan surprised local health departments in January when he delegated much of the early registration and vaccination duties to them. Local health agencies, typically small and underfunded due to years’ worth of disinvestment in the public health industry, scrambled to get their phone lines, websites and facilities up to speed.
The departments, many of which run seasonal flu clinics or handled responses to previous infectious disease outbreaks such as the 2009 swine flu pandemic, used their in-depth knowledge of community health to focus on inoculating their most at-risk residents, including older adults, people with intellectual and developmental disabilities, and the homebound.
As health officers raised alarms about fluctuating vaccine supply, the state decided to send a minimum allotment each week to each local health department — a policy that sent a disproportionate number of doses to small, rural counties. State officials now provide four-week projections of supply to health departments and consider population, efficiency and “compliance” with state policies when divvying up Maryland’s doses.
Health officers said the state didn’t provide notice before expanding vaccine eligibility, which made it challenging to run efficient clinics.
“It’s been very frustrating for us,” said Ed Singer, Carroll County’s health officer. “I’ve complained loudly about it. … The state really needs to be more transparent with what their plan is. It’d be nice if the local health departments were involved in the process.”
Tensions between local leaders and the Hogan administration have boiled over throughout the pandemic, with some calling on the governor to work more closely with them. A spokesman for the governor said the administration is readily available to talk through concerns, and speaks regularly with county executives and health officers.
Signing up everywhere
To get an appointment, the state’s top health official directed people to sign up
with multiple providers and booking platforms, a system that many argue should have been simplified from the start. Marylanders have traversed the state to locate vaccine appointments, while others with limited mobility have been sidelined.
Hogan and acting state health secretary Dennis R. Schrader said the non-centralized registration process helped avert establishing a “single point of failure,” and pushed the vaccine into multiple communities at once. After pressure mounted on the state to create a single-file line, the state health department developed a one-stop booking portal, which launched in March, for the state’s mass vaccination clinics.
The state also established a call center for its mass vaccination clinics, which has made tens of thousands of appointments.
State Sen. Clarence Lam, a member of the Senate Vaccine Oversight Workgroup, said the state could have avoided its rough start if it had opted for a simplified sign-up system and chosen not to expand eligibility abruptly in January to include all 65-plus adults, as well as people with certain health conditions and some essential workers.
“You have to match supply and demand when resources are scarce,” said Lam, a Democrat.
Schrader acknowledged that opening up immunizations to those 65 and older, rather than the initial threshold of 75 and older, complicated the rollout.
But he said the decision stemmed from concerns that most people in the older group were white.
“It did add more people, and it made it harder for us,” Schrader said. “But we felt it was worth it because of that (inequity).”
The racial and ethnic disparities in vaccinations have improved. Still, white people, who make up about 58.5% of Maryland’s
population, have received more than 2.5 times the number of first doses as Black people, who account for about 31% of residents. State figures also show Latinos have received about 5% of the initial immunizations for which the recipient’s ethnicity was known. About 11% of residents identify as Latino.
Dr. William Moss, executive director of the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health, said the Black and Latino populations have borne the brunt of the coronavirus pandemic. The groups include many people who were exposed to the virus because they could not work from home.
Now, they’re being shut out of a system that favors those with internet access, cars and flexible work schedules, critics say.
“We were not as prepared in Maryland, and across the country, as we should have been on the delivery side,” Moss said. “Operation Warp Speed was a tremendous success in the research and development of vaccines, but we were woefully unprepared on getting those vaccines into people … particularly the African American and Latinx population.”
Overestimating technology
Wendy Cohen turns 70 soon. The Baltimore County resident spent weeks waking up at 3 a.m. or earlier, hunting for a vaccine appointment online.
In the end, a friend set up three computer monitors, and spent five days and five nights looking for appointments. He found her one close to home.
“You need to be lightning-quick,” Cohen said.
Technology has served as both a barrier and a lifeline during the vaccine rollout, a digital divide exacerbated by a mostly online registration system engineered by people who likely lacked health equity experience, said Laura Moy, an associate professor of law at Georgetown University who specializes in tech policy.
“It is unequally available, and people of lower income do fail to have access in the first place,” Moy said. “It’s inequitable because it’s just plain time-consuming, and that’s not fair. And it requires insider knowledge about all of the different websites.”
Moy said such an effort required more door-to-door outreach, flyers and direct mailers to complement it.
Tiffany Tate developed PrepMod, Maryland’s vaccine scheduling system. She said officials did not anticipate that people would send appointment booking links to friends, family members and colleagues who were not eligible, creating overbooking crises at multiple clinics and causing many to lose their spots in line.
“People are doing things we’ve never imagined,” said Tate, executive director of the Maryland Partnership for Prevention, a nonprofit that works on school immunization programs. “Bots are (giving) people access. People have started businesses to do this.”
Several Facebook groups have surfaced, aiming to connect people with appointments and teaching them how to work the system.
A coalition of groups called the “Equity Vaccine Hunters” focuses on finding appointments for those most at risk of contracting severe disease, registering thousands of people considered vulnerable or hard-to-reach.
The state launched a Vaccine Equity Task Force of its own, bringing immunizers into communities. It also set up partnerships with primary care providers and hospitals to reach more people.
Still, many Marylanders remain on the hunt.
Vaccinators should have started collecting registration lists in the fall, Tate said. Preliminary research could have revealed pockets of mistrust or hesitancy in the population, she said, and helped identify the most central sites to place mass vaccination clinics. The state on Thursday opened registration for its mass vaccination clinics to all Marylanders 16 and older.
Tate said mass vaccination does not necessitate stadium venues or convention centers. The spaces can be small — as long as they’re efficient at moving people through the line. And some should be held 24 hours a day, or offer nighttime hours for people who work days.
“We have to be willing to try different things: warehouses, grocery stores, nursing homes,” Tate said. “Find them where they are, and vaccinate them where they are going.”