Ex­perts: Don’t throw out vac­cine doses

It’s bet­ter to use left­over shots than toss them

- El­iz­a­beth Weise Health · Public Health · Medical Activism · Anti-Vaccers · Medicine · Alternative Medicine · Orange County · California · U.S. Centers for Disease Control · Jerome Adams · United States of America · Florida · New York City · Andrew Cuomo · Massachusetts · Nashville · Tennessee · Pfizer · Moderna Therapeutics · Johns Hopkins University · Immunization Action Coalition · Infectious Diseases Society of America · Seminole County · Association of State and Territorial Health Officials · Johns Hopkins Center for Health Security

When the COVID-19 vac­cine roll­out be­gan, there seemed no good an­swers for what to do with left­over doses. Vac­ci­na­tors were pun­ished for giv­ing shots in vi­o­la­tion of pri­or­ity lists, while fear­ful clin­ics were con­demned for throw­ing doses away.

“Early on, the ques­tion was: ‘Is the ab­so­lute red line that you don’t throw a dose away? Or is the red line that you don’t give it to the wrong per­son?’” said Dr. Matthew Zahn, med­i­cal di­rec­tor of the divi­sion of epi­demi­ol­ogy for Orange County in Cal­i­for­nia.

Fed­eral guide­lines ex­isted but weren’t widely em­pha­sized. The Cen­ters for Dis­ease Con­trol and Preven­tion’s Ad­vi­sory Com­mit­tee on Im­mu­niza­tion Prac­tices is­sued guid­ance urg­ing “a flex­i­ble ap­proach” to the vac­cine, es­pe­cially when it was in dan­ger of go­ing un­used.

Former Sur­geon Gen­eral Jerome Adams tweeted out that if it was a case of choos­ing be­tween wast­ing vac­cine or mov­ing down the pri­or­ity groups, the cor­rect ac­tion was to put vac­cine in arms.

States how­ever, didn’t con­sis­tently em­brace or com­mu­ni­cate that to the vac­ci­na­tors in their area, said Dr. Kelly Moore, deputy di­rec­tor of the non-profit Im­mu­niza­tion Ac­tion Coali­tion.

In some cases, ad­min­is­tra­tors seemed to worry too much about op­tics and what might seem like in­equities or fa­voritism when vac­cine was in ex­tremely short sup­ply, Zahn said.

Ten weeks into the vac­cine roll­out, most hos­pi­tals, clin­ics and vac­ci­na­tion cen­ters now have pro­to­cols and sys­tems in place to make sure ev­ery last dose gets used.

“The No. 1 rule is vac­cine can­not go to waste,” said Zahn, a fel­low with the In­fec­tious Dis­eases So­ci­ety of Amer­ica. “Have a rea­son­able plan to try in good faith to reach the most el­i­gi­ble peo­ple, but don’t waste vac­cine.”

Some have em­braced that ap­proach from the be­gin­ning.

“We’ve al­ways taken the stance that ev­ery dose is a life, so we’ve never thrown a dose away,” said Alan Har­ris, emer­gency man­ager of Semi­nole County in Florida.

Just be­cause it’s the right thing to do doesn’t mean it easy. Mak­ing sure ev­ery last dose is used re­quires leg­work, Har­ris said.

Ev­ery Tues­day and Fri­day his staff call the 100 or so nurs­ing homes and as­sisted liv­ing fa­cil­i­ties in the county to find out if they have new res­i­dents or staff who need to be vac­ci­nated.

They com­pile a list, and then, if there are doses left over from a vac­ci­na­tion clinic, staff mem­bers start mak­ing calls.

“When they get that phone call, it’s de­light on the other side of the phone,” Har­ris said.

Vac­cine de­liv­ery con­tro­ver­sies

The ap­proach is a stark con­trast to in­stances when vac­ci­na­tors have been cen­sured for giv­ing left­over doses be­fore they went bad to whomever they could find.

One notorious case in­volved Dr. Hasan Gokal in Houston. He was ac­cused of steal­ing a vial of vac­cine from the Har­ris County Pub­lic Health Dis­trict on Dec. 29 be­cause he gave un­used doses that would have gone to waste to friends and fam­ily.

He filed pa­per­work ac­count­ing for what he had done and was promptly fired and charged with theft. The charges were later dis­missed.

New York Gov. An­drew Cuomo ini­tially threat­ened health care providers with a $1 mil­lion fine and loss of their li­censes if they vac­ci­nated some­one who was not el­i­gi­ble. That was walked back af­ter re­ports of clin­ics throw­ing away doses rather than giv­ing them to peo­ple who might not fit the el­i­gi­bil­ity pro­file.

Mas­sachusetts is up­front about “vac­cine wastage,” as it’s called. It makes a chart avail­able on­line show­ing tossed COVID-19 vac­cine, which in al­most all cases was dis­carded be­cause of stor­age or de­liv­ery prob­lems that let doses get too warm for too long.

The state’s vac­cine al­lo­ca­tion guid­ance specif­i­cally calls for all vac­cine to be used, even if it means mov­ing down the el­i­gi­bil­ity list.

“In the rare in­stance where you have COVID-19 vac­cine that will ex­pire and you have no one in the cur­rent pri­or­ity groups to be vac­ci­nated, you can use your clin­i­cal judg­ment to ad­min­is­ter the vac­cine to a per­son in an­other pri­or­ity group,” it says.

While the is­sue gets a lot of at­ten­tion, over­all vac­cine waste ap­pears to be very low, said Dr. Mar­cus Ples­cia, chief med­i­cal of­fi­cer for the As­so­ci­a­tion of State and Ter­ri­to­rial Health Of­fi­cials. Though there’s no ac­tual data, anec­do­tally he has not heard much con­cern about it.

“Most clin­i­cal sys­tems are ex­pe­ri­enced in do­ing this, they have stan­dards of prac­tice in place to or­ga­nize how much vac­cine they’re go­ing to need for a given clinic,” he said.

That’s the case in Nashville, Tennessee, where Siloam Health has worked to make sure no doses go un­used.

“We try to sched­ule vac­ci­na­tion pa­tients in groups of 10, be­cause there are 10 doses in a vial” of the Moderna vac­cine, said Dr. Mor­gan Wills, CEO of the low-in­come health net­work.

Vac­ci­na­tion clin­ics are sched­uled in the morn­ing, so if there’s any ex­tra vac­cine be­cause some­one didn’t show up, it can be of­fered to af­ter­noon clinic pa­tients.

The net­work also has cre­ated a list of all its pa­tients by age so staffers can call and ask if some­one can come in right away if there are ex­tras.

“We didn’t have some­body ded­i­cated to that be­fore­hand, so we had to al­lo­cate a staffer,” Wills said. “Thank­fully, we have a very de­tail-ori­ented mem­ber of our team who’s lend­ing a hand.”

Re­quire­ments boost chal­lenge

COVID-19 vac­cine is prob­lem­atic not only be­cause it’s in short sup­ply but be­cause of its ex­act­ing stor­age re­quire­ments.

The Pfizer vac­cine is shipped frozen in vials that con­tain up to six doses. To be used, the vial must first be thawed and then mixed with a sa­line solution. Once mixed, it can be held at room tem­per­a­ture, but if it’s not used within six hours it must be dis­carded.

The Moderna vac­cine also is shipped frozen, in 10-dose vials. It is brought to room tem­per­a­ture, the rub­ber cap is punc­tured and vac­cine is drawn into a sy­ringe for in­jec­tion. Once the top has been punc­tured, the rest of the vial must be used within six hours.

At many COVID-19 vac­ci­na­tion sites, a phar­ma­cist fills sy­ringes with vac­cine, which are then taken to the health care pro­fes­sion­als do­ing the vac­ci­na­tion.

“As we get closer to the end of the day, we do fewer sy­ringes to de­crease the pos­si­bil­ity we’ll have any left over. At the very last half-hour we only fill them as peo­ple come in,” said Semi­nole County’s Har­ris.

The county never has more than five doses of Pfizer (some­times it’s pos­si­ble to get six doses out of a vial) or nine doses of Moderna vac­cine at the end of a clinic. Gen­er­ally, it’s no more than two or three.

What­ever is left is put in small bat­tery-pow­ered re­frig­er­a­tors used to store in­sulin, about the size of two stacked boxes of spaghetti. These are driven by health care providers to the as­sisted liv­ing fa­cil­ity where some­one is wait­ing.

The im­por­tant mes­sage for vac­ci­na­tors is that vac­cine is pre­cious and should never go to waste, said Dr. Amesh Adalja, a se­nior scholar at the Johns Hop­kins Cen­ter for Health Se­cu­rity.

That’s es­pe­cially im­por­tant in in­clement weather when peo­ple might not make it to their vac­ci­na­tion ap­point­ments

 ?? PRO­VIDED BY SEMI­NOLE COUNTY DEPART­MENT OF HEALTH ?? A sy­ringe filled with COVID-19 vac­cine in a bat­tery-pow­ered re­frig­er­ated trans­porta­tion con­tainer. In Semi­nole County, Fla., county staff use these to take any ex­tra doses of vac­cine to home-bound se­niors or nearby nurs­ing homes af­ter vac­cine clin­ics.
PRO­VIDED BY SEMI­NOLE COUNTY DEPART­MENT OF HEALTH A sy­ringe filled with COVID-19 vac­cine in a bat­tery-pow­ered re­frig­er­ated trans­porta­tion con­tainer. In Semi­nole County, Fla., county staff use these to take any ex­tra doses of vac­cine to home-bound se­niors or nearby nurs­ing homes af­ter vac­cine clin­ics.

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