Like many older Americans, my dad wanted to get his COVID-19 vaccine but found the process of signing up for an appointment frustratingly complicated. In his home state of Oklahoma, there were multiple websites. It wasn’t clear, though, whether each site offered the same appointments or different ones. And refreshing the page at just the right time to snag a coveted spot seemed impossible. “I’ve got my annual checkup tomorrow,” he said to me. “Can’t I just get the vaccine from my doctor?”
Unfortunately, the answer was no. Americans are used to thinking of their doctor’s offices as the place to go for vaccinations, but the process for distributing the COVID-19 vaccine has largely bypassed primary care physicians. That’s something physicians themselves have been frustrated about recently. In a survey of primary care doctors, 32 percent said they hadn’t been included in any state or regional planning and had no idea when or if they would get vaccines for their patients. Years of surveys suggest, however, that primary care doctors are the most trusted source of information about vaccines and vaccine safety. A 2015 survey of Oklahoma residents, for example, found that 81 percent trusted their health care providers for health information — that’s compared with 24 percent who said the internet was a trustworthy source. (Presumably, their daughters writing on the Internet ranks higher than that.)
The exclusion of primary care doctors is just one of the many ways that a pandemic vaccine rollout differs from the normal, everyday process of getting people vaccinated. We have a process that we know works — experts I spoke to, in fact, described the United States’ normal vaccination system as one of the best in the world. So why not use it in a pandemic?
Because everything — from the logistics of the vaccines to the patients themselves — is different.
There are a number of reasons why people like my dad can’t just go to their primary care doctor for a COVID-19 vaccine, said Julie Swann, a professor and head of North Carolina State University’s department of industrial and systems engineering. The storage and distribution needs of the different vaccines, especially the requirements for ultra-cold storage, are a big part of this. Initially, the Food and Drug Administration said the Pfizer vaccine had to be stored between -112 degrees Fahrenheit and -76 degrees Fahrenheit — something most doctor’s offices couldn’t do. Nor do they have the ability to vaccinate as many people per day as public health experts say is necessary to effectively combat the virus.
“What is the maximum number of doses that doctor’s office is going to give out in a single day?” said Swann. “Even if you have more of these individual doctors, if you have 10 mass vaccination sites and each doing 5,000 shots per day, how many doctors would you need if the doctors are only giving 100 [vaccinations] per day?”
Likewise, there are time limits to how fast each vial of vaccine must be used once it’s opened, said Julie Murphy, a senior administrator at the nonprofit Immunization Action Coalition. “We’re accustomed to single-dose vials or prefilled syringes in the fridge,” she said. Even when other vaccines do come in multi-dose vials, they’re stabilized with preservatives that make them work well in a primary care setting, where you’re likely to go through five doses over a couple days but not necessarily in the six-hour time window the preservative-free COVID vaccines demand.
The absence of primary care doctors isn’t the only way COVID vaccine distribution differs from normal. For example, vaccines aren’t usually free to the public or allocated to states by the federal government. Nor are there usually reporting requirements that anyone distributing vaccines must regularly submit information on the supply left in their inventory. The process of distribution has changed in multiple ways — even from state to state or county to county. And while there are lots of ways to get vaccine distribution wrong, experts said there’s no single way to do it right either.
In fact, it’s important to remember that this vaccine distribution is different from anything else we’ve ever done before, said Dr. Yvonne Maldonado, professor of pediatric infectious diseases at Stanford University. Nobody has ever tried to wipe out a pandemic in real time like this. The closest analogy, she said, is probably the elimination of smallpox, and that didn’t have such a short time constraint. It’s no wonder, then, that what we’re doing now doesn’t always look like what we’ve done in the past.
But this doesn’t mean experts are ignoring the lessons of past vaccination campaigns. In fact, during the H1N1 pandemic, Swann was part of a team modeling pandemic supply chains for the Centers for Disease Control and Prevention. One of the things she did was analyze which kinds of vaccine distribution locations were most effective. “States that had sent more vaccine to locations that were easier for people to access had higher rates of administration of the vaccine to high-risk adults.” When she says places that are easier to access, she means pharmacies.
Open after working hours and on weekends and with no need for a prior relationship with the patient, pharmacies turned out to be really efficient at getting vaccines to more people, faster. Prior to the H1N1 pandemic, though, only some states allowed pharmacists to administer vaccinations. The lessons learned in that pandemic ended up changing laws nationwide, and now pharmacies are not only a normal place to get a flu vaccine but also a big part of the COVID-19 vaccine response.
Mass vaccination sites can leave a trust gap in who gets vaccinated, however. They’re good at efficiently vaccinating lots of people quickly — not necessarily good at vaccinating everyone. When the Kaiser Family Foundation polled Americans about the COVID-19 vaccines in December, they found that 39 percent were adopting a “wait and see” approach — they didn’t want to be among the first and fastest to get the vaccine. That same group, though, showed a lot of trust in their doctors to tell them which vaccine was safe and when it was safe to get it — 87 percent of those wait-and-seers trusted their own health care providers. Primary care doctors are likely going to become an important part of COVID vaccination later, Murphy said, when getting more people vaccinated starts to mean “getting the hesitant people vaccinated.”
In the meantime, though, primary care offices can help with another pandemic vaccination problem — catching Americans up on the everyday vaccines they may have missed over the past year. “We’ve been tracking a falloff in immunization rates across all age groups for all the other diseases,” Murphy said. “It’s a serious concern.”
It’s a pandemic, but your health matters in ways beyond just whether you get COVID. For older adults, going for an annual physical — even if there’s not a prized vaccine dose waiting — is pretty important. So that’s what my dad did. And then, undeterred by his annoyance with the system, he made a separate appointment to get his COVID-19 vaccine.