The Middletown Press (Middletown, CT)
What if you can’t get 2nd shot?
Health officials face problems with delivering 2nd vaccine doses on schedule
For weeks, Robert Rubbo, head of the Torrington Area Health District, has been fielding calls from anxious seniors trying to schedule their second dose of the coronavirus vaccine.
Residents began scheduling appointments for their second Moderna shot in mid-January, but there weren’t enough appointments to accommodate everyone. So Rubbo has re-routed his staff and recruited additional volunteers to nearly double the appointments in his three weekly clinics.
“We were getting a lot of phone calls. People were concerned — they couldn’t find appointments for the second dose,” he said. “We felt the need to try and open this up to help them out. We didn’t want them to get left out there without a clinic.”
It’s a problem playing out across the state, as some seniors have received first doses without being able to schedule a second. Besides stoking fears among residents that they won’t get their second vaccination in the proper time frame, the scheduling issue is giving the state inventory head
State Sen. Matthew Lesser, D-Middletown, said the issue stems from computer systems that don’t allow first- and second-dose appointments to be scheduled simultaneously. But providers can help by setting up patients’ second appointments when they show up for their first vaccine, he said.
aches.
Making matters worse, Connecticut’s vaccine providers are interpreting international, federal and state guidance differently as they determine how closely they want to stick to the original second-dose time frame outlined by Pfizer and Moderna. Providers are also following different policies on the scheduling of second doses — some allow residents to schedule them when they receive the initial shot, as the state Department of Public Health recommends, but others don’t, leaving people to fend for themselves.
And when residents book their second doses at clinics where they did not get their first vaccine, inventories can get stretched thin.
State data confirm that the rollout of second doses hasn’t been perfect, but officials say they understand the glitches and are working to fix them.
How much time should go by between doses?
When seniors have trouble scheduling a second vaccine, the question of timing can quickly become a concern. What if they miss the window?
The state is caught in a delicate balancing act between communicating evolving public health guidance and allaying fears.
The Centers for Disease Control and Prevention has indicated that people should get their Moderna second doses after four weeks and Pfizer second doses after three weeks from the initial shot, though it also has said that people can wait up to six weeks to get their second dose if the recommended time frame is “not feasible.” The World Health Organization agrees.
Pfizer said it does not have data on immunity for those who receive their second dose after 21 days. The company did not say the vaccine is ineffective beyond that window, but a spokeswoman for Pfizer said she doesn’t have information on how effective it might be.
The state Department of Public Health’s spokeswoman Maura Fitzgerald on Jan. 21 responded to second dose concerns from local officials on a private message board set up by the state.
“They shouldn’t worry about the window for the second app[ointmen]t. The 21 day or 28 day is the EARLIEST they should get a second dose. There is no deadline for the second dose,” she wrote. “We want them to get it as soon as they can, but there’s no harm if they have to wait.”
“We always follow the CDC guidance, and so does the Connecticut Department of Public Health,” said Stephen Mansfield, director of the Ledge Light Health District, which covers a cluster of southeastern Connecticut towns, including East Lyme, Groton and Ledyard.
“Right now, the most recent guidance is that if somebody gets vaccinated, say with Moderna on Jan. 1, then 28 days later, they’re eligible for the second vaccination. But there’s about a two-week window after that, where they believe the vaccine is just as efficacious. So we’re encouraging people not to get too wound up if they don’t get their vaccine on the day.”
But Dr. Reginald Eadie, president and CEO of Trinity Health of New England and a co-chair of the state’s vaccine advisory panel, is taking a more cautious approach. “The most recent recommendation or scientific literature that I read was plus or minus about four days,” said Eadie. “It is my opinion that we should follow the science, and I support the plus or minus four days. But my current opinion is [also] we need to make sure that once we give someone their first dose, in that plus or minus four days — if it’s Pfizer, within the 21 days, or 28 days for Moderna — that they get their second shot.”
Hartford HealthCare providers are also sticking close to the timetable set forth in the clinical trials.
“The guidance is that you have a little wiggle room on either side, but we’ve kept it pretty much still at the 21to 28-day [window],” said Dr. Jim Cardon, chief clinical integration officer for the health care system.
During the White House’s COVID-19 press briefing Monday, CDC Director Rochelle Walensky laid out the potential consequences of exceeding the 21 and 28 day windows.
“There are obviously concerns if we don’t go with what was done in the trial themselves — that the vaccine would be less durable, it wouldn’t work for as long, and then of course there is an ongoing concern that we would see the emergence of more variants if there was low level virus and it was allowed to mutate. So until we have further data … we intend to follow the trials and to use the science,” Walensky said.
Giving people the maximum immunity possible is critical as more infectious variants take hold in the country, especially while vaccinating most vulnerable populations, said Saad Omer, a Yale epidemiologist. Moderna is reportedly developing a third booster dose of the vaccine, according to NBC News.
Logistical challenges
In theory, providers in the state receive vaccines only when it is time to put them into the arms of Connecticut residents. For every Pfizer first dose the state receives, it receives the corresponding second dose three weeks later. For Moderna, the second shot arrives four weeks after the first. The state and federal government together make sure the doses get where they’re supposed to go.
But how many people have not received their second dose in time because of scheduling problems, and how many people are at risk of missing their window?
Josh Geballe, the state’s chief operating officer, acknowledged reports that residents are struggling to make second dose appointments in the timetable outlined by the vaccine manufacturers, but he said he doesn’t expect those who have missed their ideal second shot window to be a large percentage of those vaccinated.
One measure of efficiency in the vaccine rollout is to compare the number of vaccines the state has received to how many it has administered. If every dose received goes into someone’s arm, the system would be 100 percent efficient. By that measure, as of Monday, the state had used 45 percent of second doses on hand but had used 85 percent of first doses on hand, according to data provided by the governor’s office.
The question is if those figures indicate a significant choke point in the process of getting vaccines into arms. If only 45 percent of available second doses have been used, does that mean 55 percent are just sitting around, waiting for seniors who are struggling to make an appointment?
The situation isn’t as dire as it seems. Even though the state has many available second doses, they cannot all be administered now.
For example, CVS and Walgreens, which are administering the vaccine to residents in long-term facilities, did not initially use all of the vaccines distributed to them, leaving them with a surplus. The federal government formula determining how many vaccines to set aside for the providers over-allocated doses for their use. So the state dialed back its allocation to allow CVS and Walgreens to work through the first doses on hand. Meanwhile, the second doses corresponding to their initial over-allocation are arriving on their original schedule, giving them now what appears to be a surplus in second doses. But as the days go by and more residents hit the eligibility window, those doses will get used.
If one looks at the number of doses that can be administered by now — as opposed to simply the number on hand — the state has used 79 percent of second doses in nursing homes and other long-term facilities and 67 percent of second doses in other settings, bringing the combined total to about 70 percent.
The gap that matters is between the 70 percent of second doses available to be administered and 85 percent of first doses administered, suggesting that the state is not rolling out second doses as efficiently as it is doing with first doses.
Finding ways to ensure second-dose appointments
Until this past Sunday, providers using the federal Vaccine Administration Management System — the majority of providers in Connecticut — could not make a distinction between first- and second-dose appointments, said DPH Acting Commissioner Deidre Gifford. That glitch has been fixed.
“We’ve been working with our providers all week to make sure that they can identify who needs a second dose that doesn’t have it scheduled. We’ll get those makeup clinics scheduled so that people can come in and any backlog that there is on second doses will get swiftly worked down in collaboration with our partners.”
“There are definitely problems with people scheduling second doses. DPH seems very much aware that this is a statewide problem they’ve got to fix,” said Sen. Matthew Lesser, D-Middletown, who has participated in the calls. “I’ve been on, like, three calls today where people from the state have acknowledged it’s a huge problem.”
Lesser said the issue stems from computer systems that don’t allow first and second dose appointments to be scheduled simultaneously. But providers can help by setting up patients’ second appointments when they show up for their first vaccine, he said.
State health officials are encouraging providers to book people’s second vaccines when they report for their first dose. Some hospital systems and local health districts have already started doing that, though it’s not a consistent practice statewide.
The state has no immediate plans to require that providers schedule a patient’s second dose at the time of the first shot, Gifford said. But officials are working with providers to resolve the access issues.
“One of the reasons we’re doing relatively well in our rollout is that we’ve tried not to put a lot of stringent requirements on providers, because we know this is a very complex program with a lot of moving parts,” Gifford said. “Our strategy really is collaboration, listening, and feedback. We’ve been working with all the providers that we have identified are having second dose scheduling challenges and problem-solving with them.”
Stephanie Hilliary-Leahy, a neonatal nurse Connecticut Children’s Hospital in Hartford, got her second Pfizer vaccine a few days past the 21 days, a decision she made to accommodate her schedule. While she wasn’t able to schedule the second shot when scheduling the first, the clinic setup a practical solution.
“My employer’s clinic made it so easy. As soon as the first was in my arm, computers were available in the observation room to sign up for the second,” she said. “I know many folks are complaining that it’s been challenging, but my experience was really easy.”
“The most important thing to say is, would I do it all over again: Yes. Science is amazing and this vaccine works,” she said.
Residents don’t need to get their second shot at the same clinic that they got their first — though they do need to get a second shot from the same vaccine manufacturer. When residents go elsewhere for their second dose in an effort to stay on schedule, “it throws off your vaccine inventory,” said Patrice Sulik, director of the North Central District Health Department, which includes Enfield, East Windsor, and several other north-central towns. “We order first doses, and then the second doses that accompany those first doses are automatically supplied. So if we’re giving a lot of second doses where we didn’t give the first dose, it throws off the numbers.”
Frustration and trust
Nilda Paris usually spends her time bringing information about programs and services to residents who face barriers to the health system, such as transportation, finances or shelter. She also helps them access rental and food assistance. But lately, a lot of her job as a community health worker has involved helping people sign up for COVID-19 vaccines.
The mixed messaging has made that more difficult, she said. “All this information is coming out. One day they say one thing and the next day they say another thing,” Paris said. “It’s bringing more confusion.”
For Sen. Will Haskell, D-Westport, the issue is personal. Haskell’s grandparents, who are in their 80s, were struggling to find appointments to receive a second dose of the Moderna vaccine.
“Frankly, I’ve had that frustration in my own family,” he said. “I’ve been helping my grandparents through the process, and they were so thrilled to get vaccinated at Norwalk Hospital. But they haven’t signed up for a second appointment yet because they’ve been unable to do so. There are just no slots open at the 28 days that is recommended.”
“They don’t want to have to wait unnecessarily,” he added. “And they certainly deserve peace of mind to know they’ve got that second appointment booked.”