En español | The federal government has delivered more than 29 million doses of COVID-19 vaccine to states, territories and tribal governments as of Jan. 13, but only about 10.3 million, or 35 percent, have been administered, according to tracking by the Centers for Disease Control and Prevention (CDC). While that rate has been ticking up in recent days, it still means millions of shots are sitting in storage. In a handful of states, the vaccine administration rate is 25 percent or less.
A vaccination campaign unprecedented in its complexity and scope has been slowed by several obstacles, some predictable, some not. Here are the key issues that have dogged the rollout during its first month — and some of the steps being taken to address them.
1. This has never been done before.
Operation Warp Speed, the partnership between the federal government and major drug companies to rapidly develop and distribute COVID-19 vaccines, reached its first goal with unrivaled success. Past vaccines like those for polio and flu took years, even decades, to develop. The Pfizer and Moderna COVID shots were created, tested and authorized for use in just nine months.
But that speed had a “downside,” said Eric Toner, M.D., a senior scholar at Johns Hopkins University’s Center for Health Security. “It leaves less time to have a carefully planned rollout of the vaccine, for both the feds to figure out how they’re going to get the vaccine to the states and for the states to figure out how they’re going to distribute it and educate the public.”
In October 2019, the center staged a simulation called Event 201 aimed at gauging American and global readiness for a worldwide pandemic. The timing was coincidental — the center had held several such exercises since 2001 involving a range of potential public health crises — but the scenario was eerily prescient, positing a new strain of coronavirus that leaps from animals to humans and spreads rapidly around the globe, stalling economies, halting travel and setting social media afire with disinformation.
But as participants gamed out the medical, financial and logistical challenges such a pandemic could (and, as it turned out, did) present, how to quickly and effectively inoculate people against this new coronavirus didn’t come up. “We never anticipated that we’d be able to have effective vaccines in less than a year,“ Toner said. “That’s never happened before.”
Add to that the particular complexities of the Pfizer and Moderna vaccines, the two authorized for use to date. Both require extremely cold storage (especially the Pfizer shot) and two doses to achieve full efficacy. “It would have been surprising if it did go perfectly,” Toner said.
2. Vaccine supply is limited and uncertain.
Dose delivery fell short of expectations almost from the start. On the campaign trail in 2020, President Trump touted a goal of 100 million vaccine doses by year-end. Even after the administration revised that target down to 20 million, many states saw their weekly allocations from the federal government reduced shortly after the initial vaccine shipments in mid-December.
“The challenge we face is that week by week, we don’t know how many doses we will receive, making it difficult to plan for more than a week in advance,” Colorado Gov. Jared Polis said this week.
That challenge has trickled down to the health care providers that are putting shots in arms. “The unpredictable nature of vaccine shipments has challenged hospital vaccination efforts, including for staff,” said Maryellen Guinan, principal policy analyst at America’s Essential Hospitals, an association of public and nonprofit hospitals serving a safety-net role. “The inability to know the exact number of doses to be delivered and the timing of deliveries directly impacts vaccine scheduling.”
The two-shot regimen has also affected supplies, with the U.S. Department of Health and Human Services (HHS) initially holding millions of doses in reserve as second shots for people who’ve gotten the first. The agency recently started releasing those doses to further enhance available stocks, in conjunction with its call for states to open up vaccination to people age 65 and over and other vulnerable populations. HHS Secretary Alex Azar said on Jan. 12 that Moderna and Pfizer are producing enough vaccine that “we can now ship all of the doses that had been held in physical reserve, with second doses being supplied by doses coming off of manufacturing lines.”
Some states said that even with increased availability they will struggle to vaccinate an exponentially larger pool of eligible people. “There are simply vastly more Georgians that want the vaccine than can get it today,” Georgia Gov. Brian Kemp said at a news conference this week. “I would prefer that we have ample supply and that we could vaccinate everyone immediately. Unfortunately, that is simply not possible.”
3. States were left largely to their own devices.
The federal government spearheaded vaccine development, but decisions on how to distribute and administer shots have been left largely to state and local officials, creating a patchwork of plans and priorities, public health experts say.
“For the vaccine rollout, as we’ve seen for so many other parts of the pandemic response, it’s been very much left to the states to take up the responsibility for making public health come alive on the ground,” said Howard Koh, M.D., a professor at the Harvard T.H. Chan School of Public Health. “We need the federal coordination and leadership now.”
Leana Wen, M.D., an emergency physician and public health professor at George Washington University, praised the federal government’s announcement this week that it would help states expand their vaccine provider networks and set up mass inoculation clinics to speed vaccination but said the feds took a long time to step up.
“It’s almost as if they saw their role in Operation Warp Speed as developing the vaccine, which is no small task, but they saw it as developing the vaccine and then shipping the doses to the states. Their responsibility appeared to stop at that point,” said Wen, who formerly served as Baltimore’s health commissioner. “But that is not the way this should be done. This is a federal, state, local partnership. The federal government needs to be the one that’s setting the tone, the urgency that’s needed.”
4. Public health departments are underfunded.
Years of budget cuts have hamstrung the ability of state and local health agencies to respond to outbreaks and other emergencies, according to a 2019 report by the nonprofit Trust for America’s Health. COVID-19 further stretched thin resources, as local health services took on much of the burden of testing, contact tracing and, now, vaccination, said Jennifer Kates, a senior vice president and health policy analyst at the Kaiser Family Foundation.
“Until this last stimulus was passed, the amount of money that they had received for vaccine distribution was very small relative to the task,” Kates said, referring to the $900 billion COVID relief bill Congress passed in late December, which includes $8.75 billion for vaccine distribution. “You add that to years of underfunding of public health — states were already acting at a deficit and some states had more of a deficit than others. That is certainly a factor here.”
“I suspect the biggest limiting factor is personnel to administer the shots,” Toner said of the pace of the rollout. “If that is the case, finding ways to augment [public health] personnel would be very helpful.” Some states, including West Virginia and Maryland, are deploying National Guard units or the volunteer Medical Reserve Corps to assist their professional health care ranks with vaccine administration or logistics.
The new federal money should also stimulate vaccine speed, Kates said. While only about half of the vaccination pot is set aside for states and localities, she noted, “I think there’s no question that money will make a difference.”
5. Hospitals were already overwhelmed.
The initial vaccine shipments went largely to hospitals charged with administering shots to their frontline staff. They arrived just as these facilities were facing a record crest in COVID-19 caseloads, complicating in-house inoculation efforts.
“These are hospitals that are already responding to huge surges in their communities,” Wen said. “Now you’re also asking them to administer doses or to pull their nurses from their normal shifts to also give doses, and the same individuals coordinating the surge at their hospitals are also overseeing this effort.”
Those issues remain even as vaccine eligibility broadens and hospitals prepare to administer even more shots, to people beyond their workforces. “One essential hospital, faced with a surge, had to reinstate a decision to eliminate elective surgeries, allowing it to reposition staff to aid vaccination efforts,” Guinan said.
Azar said this week that large-scale vaccination clinics, supported by the federal government, would reduce reliance on hospitals. “Hospitals made sense as early distribution sites when the focus was on health care workers, but they are not where most Americans go to get vaccines,” he said. “States should move on to pharmacies, community health centers and mass vaccination sites as desired.”
6. Not everyone wants the shot.
Two of the high-priority groups targeted at the outset for fast vaccines — frontline health care workers and long-term care employees — have also been among those most reluctant to get COVID shots, even as surveys show vaccine hesitancy waning among the broader public.
“Reports and internal surveys of hospitals show 30 to 50 percent of their health care workforce citing a hesitancy to be vaccinated,” Guinan said.
At long-term care facilities, staff willingness to get the shot has "been as low as 20 percent and in other buildings as high as 80 percent," said Mark Parkinson, president of the American Health Care Association and National Center for Assisted Living, an industry group. "We think the overall rate is probably in the 45 to 50 percent range."
That can create delays and keep vaccines on shelves, if there aren’t enough willing participants at a long-term care center to schedule an on-site vaccine clinic.
Hospitals and long-term care facilities are embarking on vaccine education campaigns and even offering employees incentives to get the shots. Toner and Parkinson said they expect reluctance to abate as more and more workers see friends and colleagues safely getting shots.
“There’s vaccine hesitancy and then there’s, ‘I don’t want to be the first one to get the vaccine,’” Toner said. “I hear that from people working in the hospitals. It’s not irrational. But I think once people start seeing their friends and colleagues getting vaccinated and there’s no problems, they will be amenable to it.”
7. States set aside doses for high-priority groups.
There was near-universal agreement among federal and state health officials that early distribution target high-risk health care workers and residents and staff at long-term care communities, but that initial exclusivity kept shots on shelves as vaccination programs at some sites stumbled.
For example, millions of doses allocated to the states on paper actually went to CVS and Walgreens, the giant drugstore chains contracted by CDC to deliver shots in most of the country’s nursing homes and assisted living facilities. That effort has gotten off to a notably slow start, with about a quarter of the allocated shots administered so far.
Given the vulnerability of long-term care residents and staff, who’ve accounted for 37 percent of the country’s COVID-19 deaths, “states feel an obligation to hold that vaccine in the hope that this week or soon they’re going to be up and running,” Toner said. (CVS and Walgreens have said they will complete first doses at all facilities by Jan. 25.)
But with shots going unused, federal officials have criticized state leaders for not opening up eligibility to other vulnerable groups, such as the 65-plus population and people with medical conditions that put them at high risk for complications from COVID-19.
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“There was never a reason that states needed to complete vaccinating all health care providers before opening vaccinations to older Americans and other vulnerable populations,” Azar said this week as he urged more states to expand vaccine access to those 65 and older. “Some states’ heavy-handed micromanagement of this process has stood in the way of vaccines reaching a broader swath of the vulnerable population more quickly.”
Some states have adopted a use-it-or-lose-it approach, reallocating doses from health care facilities that are not using them quickly to those with a higher rate of shots reaching arms. HHS has embraced this strategy and is now basing vaccine allocation to states on their reported “pace of administration” and the size of their 65-plus population, Azar said.
Wen called this shift “the best thing” public health leaders can do to accelerate vaccination. “If you have these doses, it’s your responsibility to use it immediately, recognizing that there are plenty of other institutions that are capable and willing to use these doses,” she said. “Setting that type of urgency and expectation from the very top is really critical.”
Catherine Maddux contributed to this article.
Editor's note: This article has been revised to clarify information about the federal government's release of vaccine second doses.