The failures of the United States public health system to respond to COVID-19 are multiple and well documented. From the CDC botching tests in March, to irregular messaging regarding masks, poorly timed shelter-in-place orders and now the bottlenecks in vaccine rollout the country has misstepped at every conceivable juncture. Now we are at our most critical and, perhaps, most tragic juncture because we have not one but two effective options to stop the pandemic – Pfizer/BioNTech (95% effective at 28 days) and Moderna (94.1% effective). Pfizer obtained FDA clearance on December 11th, Moderna on December 18th.  This Friday, January 8th will be day 28 from the Pfizer approval – deaths that occur after this date can and should be considered to be entirely preventable.

Now I’m not naive enough to believe that the United States could roll out 660 million doses and vaccine the entire population between December 11th 2020 and January 8th 2021. On the other hand, the current data on vaccination rollout nationally (link: https://covid.cdc.gov/covid-data-tracker/#vaccinations) points to our failure (again):

-17 million doses distributed with 4.8 million individuals receiving their first dose (28% effective vaccination rate)

-3.2 million doses distributed to long term care facilities with 429,000 individuals receiving their first dose (13% effective vaccination rate)

California is underperforming the national average – with over 2 million doses received, only 456,980 have received their first dose (22.4%). California is also the current national epicenter of the COVID-19 epidemic (link: https://covid.cdc.gov/covid-data-tracker/#county-view) with Los Angeles, San Bernardino, Orange and Riverside Counties having the highest infection rates in the country.

At a certain point, we move from run of the mill failure to abject failure – and Los Angeles County is now the standard bearer of worst in class response to the pandemic. With cure in hand, the County is now botching rollout, hoarding vaccines and causing tragic and unnecessary morbidity and mortality.  The linked Los Angeles Times article (link: https://covid.cdc.gov/covid-data-tracker/#county-view) draws you in with the flashy headline that non-prioritized individuals have been able to obtain vaccines. But that’s not the most appalling fact in the article, this is:

“Crowds of desperate people seeking early access to the vaccine led to longer lines and headaches for workers at four sites run by the city of Los Angeles set up to provide doses exclusively for healthcare employees.”

Desperate people in a County of 10 million people, a City of 4 million and the public health response?  Four vaccination sites.

My personal experience and attempts to secure vaccines for our clinic has been equally frustrating, maddening and outrageous. We applied and were certified to be a community site for vaccine delivery by the State of California on December 17th – receiving the following chipper response:

“Congrats on being COVIDReadi! With your help and the help of the California healthcare provider team, entire communities will be COVID Ready quicker and more effectively than any vaccination effort in our history.”

When I received no further follow-up from the State I began to ask when I might expect vaccines to be delivered (a not unreasonable request). The State Health Department responded that I needed to ask my local Health Department. Our local Health Department responded that I needed to ask the CDC.  The CDC responded that I needed to speak with somebody at the state-level.

Around and around we go. So how did this get so messed up? The answer probably won’t be surprising, but the fundamental stumbling block is at the top with the CDC.  And here is the root cause -from their vaccination “playbook” drafted in October 2020 (link: https://www.cdc.gov/vaccines/imz-managers/downloads/COVID-19-Vaccination-Program-Interim_Playbook.pdf)

On Page 17 of the playbook, the CDC notes that “To improve vaccination among critical population groups, jurisdictions must ensure these groups have access to vaccination services.” To do so, they suggest that “programs should establish points of contact (POCs) for each organization, employer, or community (as appropriate) within the critical population groups.”  Here is their list of suggested points of contact:

• Community health centers 
• Federally Qualified Health Centers
• Rural Health Centers 
• Critical access hospitals
• Pharmacies 
• Organizations and businesses that employ critical workforce 
• First responder organizations 
• Tribal health or community centers 
• Non-traditional providers (e.g., community health workers, doulas, promotoras) and locations (e.g., dialysis centers, community centers) serving people at higher risk for severe illness 
• Other locations or facilities for shared or congregate housing serving people at higher risk for COVID-19 illness (e.g., homeless shelters, group housing, correctional facilities, senior living facilities) 
• Locations where people 65 years of age and older gather (e.g., senior centers, food pantries) 
• Religious groups and other community groups 
• In-home care organizations 
• Schools and institutions of higher learning

Notice anything missing? I do – doctor’s offices. Why is this such an oversight? Well the reason can be found in the CDC’s own data on flu shots. Here are the breakdown of locations of where adults receive their flu shot (most recent data are from 2018 as for location is only collected every three years – link:  https://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2018.htm)

1. Doctor’s office (34.3%)
2. Pharmacy/Store (32.2%)
3. Workplace (14.9%)
4. Clinic or health center (7.9%)
5. Emergency Department (5.4%)
6. Other place (1.9%)
7. School or college (1.4%)
8. Health Department (1.0%)
9. Senior or community center (0.3%)

Doctor’s offices are the largest provider of flu vaccine for adults – that number skyrockets to 67.7% of children. Typically Health Departments which are now charged with the ENTIRE burden of vaccine distribution only supply 1% of flu vaccines.  1%! Yet the CDC completely overlooked doctor’s offices – this in the face of other potential sites being overburdened (Emergency Department and Health Department) or non-viable (workplace, as many are closed due to safer-at-home restriction). Further, the percentage of flu vaccinations performed at a pharmacy is largely a function of convenience – i.e. people are already there picking up prescriptions or shopping so they get their flu shots at the same time. But, again, with the population being asked to limit movement, there are far fewer of those vaccination opportunities. Add into this calculus that the COVID-19 vaccines are a series of 2 shots – so any inefficiencies in the system will be multiplied by a factor of 2. Standing in a long line for hours? You’ll do it twice. Traveled a long distance to get a shot? You’ll do it twice. Any inconvenience reduces the likelihood of individuals completing the vaccine series – leading to no protection or partial protection thus creating an environment where viral mutations can thrive.

In the final analysis, the effectiveness of any vaccine distribution effort can be easily measured as a function of doses delivered by doses available. At this writing – nationally, 28% of available vaccination doses have been administered and in California that percentage drops to 22%.