How vaccine gets from the manufacturer to your arm — and why it’s taking so long

Still waiting for your coronavirus shot? Let’s just say the country’s vaccine pipeline has been suffering a few clogs.

Yes, we’re all frustrated. And that includes Desi Kotis, chief pharmacy executive at UCSF Health.

She has been helping lead UCSF Health’s vaccine distribution program and insists they are just itching to get a shot into everyone’s arm if it wasn’t for the three ugliest words in the vaccine world these days: lack of supply.

“There’s no rhyme or reason to how vaccine is being allocated from week to week,” she said. “Everything is sporadic and random.”

So what’s gumming up the works? How has the most powerful nation on Earth set up its system to rush vaccine delivery to clinics, pharmacies and medical providers from San Jose to Sarasota, Florida? And how might it work better?

Here’s a quick overview of how the system is supposed to work: First, the U.S. government buys doses from the vaccine manufacturers — Pfizer, Moderna and Johnson & Johnson. The government has spent billions of dollars, much of it invested as vaccines were being developed, to produce and acquire millions of doses. Then, it allocates vaccine using a system that relies on Census data. A lot of the vaccine goes to states, like California. Some of it goes to big national vaccine providers like CVS and Walgreens, some of it goes to the VA to vaccinate veterans, and some of it goes to what are known as federally qualified health clinics across the country.

The vaccine isn’t physically moving at this point, though — everything is still happening online.

When California learns about its shipments, the state divvies up vaccine to different providers with the help of Blue Shield, which the Newsom administration tapped to centralize the Golden State’s distribution. Some counties, like Santa Clara and Los Angeles, worked out agreements to help call the shots on where vaccine should go within their borders. But the state, again with Blue Shield’s help, still decides how much vaccine should go to major health providers like Kaiser, Sutter, Dignity and the UC system hospitals.

Complicating all of this in California is the state’s effort to initially send more vaccine to vulnerable populations — mostly in the Central Valley and Southern California — than wealthier, healthier areas where the virus has been less deadly. Another twist? In the past, vaccine allocation depended in part on where eligible populations lived — those 65 and older, those with certain jobs, like nursing, for instance. Now, with vaccine eligibility set to open on April 15 to everyone 16 and older, the state is pivoting to provide vaccine where the most people reside.

When it’s time to finally ship the vaccine, Pfizer handles its own distribution while Moderna and Johnson & Johnson rely on McKesson, a major pharmaceutical service company with a long history of distributing everything from prescription drugs to flu vaccines. All three count on UPS and FedEx to get shots to hospitals, pharmacies and clinics across the country.

So why aren’t things running smoothly? What could make it work better?

Vaccine hunters in the Bay Area like Tracey Bilter want to know. “This is a nightmare,” she said recently. “No appointments available within 50 miles and the system is so disjointed. I am answering the same questionnaires over and over, only to be told there is no availability.”

Kotis, at UCSF Health, has a theory. It makes sense, she said, to have the government involved in things it’s good at, like creating and maintaining one of the best militaries in the world. But “drug distribution is not their forte and that’s the failing,” she said. “There’s not been a standard, logical way to get vaccine distributed to us who are getting them into people’s arms.”

She talks to her UC counterparts across the state regularly and says they have been especially frustrated by the unpredictability of how much vaccine they are slated to receive. Kotis said she would rather be able to use the traditional drug supply model — ordering from drug wholesalers experienced in distribution — with some rules around stockpiling or other guidelines in place.

“We know how to work with distributors. We know how to order,” Kotis said.