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According to Bloomberg News global vaccine tracker, 5.7 percent of the U.S. population has been fully vaccinated. 

I depress the plunger hard, and the retractable needle pops into the hub like magic. Just like I was told it would! This is the fourth type of needle I have used today, and I am only 2½ hours into my shift. This is the first time I have ever used this type of needle. We vaccinators have to be agile, and take what we get.

I strip off my gloves, adjust my N95 mask so the metal strip isn’t digging into my nose quite so much, and snap on a new pair, ready for the next arm.

Serving as a vaccinator with the Cuyahoga County Board of Health (CCBH) through the Ohio Medical Reserve Corps, I am becoming very familiar with the process they have established for mass administration of COVID-19 vaccines. It also has made me very cognizant that administering vaccines in bulk is not for the faint of heart. I’d like to share the experience with you. Obviously, this is not universal, but it is representative.

It is really a feat to run these mass vaccination events. The duties are: registration verification, documenting, inventory management, vaccine preparation, vaccinating, post-vaccination monitoring, and traffic control. Nonmedical personnel do not handle vaccines or respond to anyone having a medical issue in the observation area.

For more than an hour prior to the arrival of the vaccinees, volunteers and workers have been preparing for the onslaught. Our clinic is located at the Cuyahoga County Fairgrounds. We are gathered in the Home and Hobby Building, which is a huge structure with four large garage doors on the entrance side and two doors on the exit side. This establishes the traffic pattern and allows wind to whip through the building. They strategically set up humongous, loud heaters to attempt to control the climate so the vaccinators’ and documenters’ fingers can function.

The first lane is a straight shot, door to door, so we can line up four vaccination stations. Two of the doors guide people to the other lanes, which have two stations each. They merge to exit out the other back door, so traffic control is critical to ensure safe passage. We can only set up eight stations in order to accommodate the massive trucks that those EMS and firefighter personnel drive. When a vaccinator arrives, they stake their claim for their spot. I try to get one of the middle two stations in that first lane, which is considered the “fast lane.” We will go through about 1,200 vaccines in eight hours, which represents about a vaccine every three minutes or so, although sometimes there are two people in one vehicle, and sometimes a van comes with multiple disabled occupants from a congregate living facility.

At this time, we only have Pfizer and Moderna vaccines available to us under emergency use authorization. We get inventory of each per the whim of the manufacturers and the government, and we must adjust our procedures accordingly.

It is an awesome responsibility to handle the vaccine, and I was nervous the first time I served as a vaccine preparer. With Pfizer, there is a medical lead person who removes the vaccine from the cooler and doles out the product and diluent. The vaccine was thawed in the refrigerator 24 to 48 hours in advance of our vaccination event. We are dispensed a single vial at a time.

Although the general Centers for Disease Control and Prevention (CDC) instructions are that a vaccinator should prepare their own vaccine to ensure the provenance, when working with these COVID-19 vaccines, we separate out the duties of vaccine preparation and administration out of sheer necessity. When we are in the busiest part of the day, there are even dedicated people whose task it is to assemble the needle/syringe complexes, and then others draw up the vaccine.

You need to make sure you are swirling Moderna, and drawing up exactly 0.5 ml. Pfizer needs to be gently inverted 10 times, and only 0.3 ml are used for each dose. This is not a martini – don’t shake either, or you will have to waste the vaccine!

It is really important to follow the manufacturer’s procedures and guidelines. There are very precise instructions about how to thaw, mix, draw up, and use vaccine in a timely fashion. Pfizer is shipped and must be maintained at insanely low temperatures (between -80°C and -60°C, or -112°F and -76°F), and the people who monitor the vaccine supply must ensure that there are no temperature variations. If the temperature falls outside the acceptable range, the vaccine may not be used.

I call over the medical lead after doing my own check that the needles are tightly affixed to the syringes. I don’t want any of the precious vaccine to leak out. I am heartsick. Three out of the ten syringes I have been supplied with by the runner have bubbles large enough to see without my reading glasses – in other words, BIG bubbles. Air in the syringe means vaccine has been displaced. Instead of 0.5 cc of Moderna, these syringes hold about 0.3 cc of vaccine. Our instructions are to waste these syringes rather than inject them in someone who might not get fully vaccinated, and thus finding themselves unprotected due to inadequate volume. Liquid gold (platinum?) is rejected into the red needle bin. The vaccine preparer is deployed and redeployed out into the elements to monitor people for adverse effects during their 15-minute observation period.

Vaccine shipments are accompanied by ancillary supply kits, which include syringes and various gauge needles (22- or 25-gauge). Everyone is trying (praying) to extract a bonus dose from each vial. Pfizer supplies special low-dead-space syringes; however, they supply only enough for the intended number of doses per vial (e.g., 5 for Pfizer and 10 for Moderna), so there may be too few needles and syringes to utilize all the available vaccine. Those low-dead-space syringes are not easy to come by.

The 25-gauge needles are pretty painless, even when an inexperienced physician is administering the inoculation. As a result, we scramble to find alternate sources of the thinner, better-received 1-inch, 25-gauge needles, rather than resorting to more painful, larger, or longer needles. The regional hospital coordinator sends out a distress call requesting supplies from nearby hospitals (hence that new-fangled retractable needle I used for the first time, mentioned at the beginning of this article). Unfortunately, if we can’t procure low-dead-space syringes, we may not be able to wrest that elusive sixth dose out of the vial. We are not permitted to pool the remains of vials to cobble together another dose, even if they are all from the same lot.

“Do you have any extra vaccine?” I get asked this question multiple times a shift. Sometimes the driver is the vaccinee; sometimes it is the passenger. The answer is: I’m sorry, we don’t. There is a delicate balance struck between second-dose recipients and first-time vaccinees during the clinic. People have gone on the Cuyahoga County Board of Health (CCBH) website, signed up for an appointment, and are anticipated. It amazes me how well they match attendees with vaccine supply. Each shift, they must also schedule 10-20 new volunteers who will get their first dose, and multiple staffers who are getting their final dose. I have not experienced a situation in which we are scrambling to find an arm to put a dose in to avoid wasting it, although I have seen such segments on the news.

At the end of a vaccination event, the vaccine coordinator does “the dance.” She determines how many more people are waiting in registration and in line, how many doses are on the floor in coolers, how many more vials need to be prepared, and how many more syringes need to be drawn up. I couldn’t do the math with a calculator; she is doing it in her head. On the floor, whereas we get 10 syringes at a time during the bulk of the day, toward the end of the shift, we only get two or three syringes at a time.

The same dance happens when we are finishing up a manufacturer lot. We need the lot numbers on the vaccine record cards to match the lot number received, so the switchover has to be quick and complete. Additionally, if you are trying to inject an arm every three minutes or so, you don’t want there to be a lag during the switchover, such that someone is left waiting to be vaccinated.

It takes a village to man a mass event such as this. The local Emergency Management Agency (EMA) and local Board of Health coordinate with local Emergency Medical Services (EMS) and Community Emergency Response Team (CERT). The state resources support the local/regional efforts. The local Medical Reserve Corps (MRC) provides medical personnel; they are actively recruiting doctors, nurses, physician assistants, dentists, pharmacists, and other licensed medical professionals (even if retired). The Cuyahoga County MRC has over 1,600 volunteers.

Every time I participate in these events, I ask the CCBH folks with whom I am working what they do in real life. I have volunteered alongside people whose primary responsibility is water quality, monitoring sexually transmitted infections, and inspecting for food safety; one of the overseers of operations is the program manager of swimming pool and spa safety for his full-time job. It is fascinating – COVID-19 is considered an “all-hands-on-deck” occurrence. I understand that the CCBH has approximately 150 employees, and although about 50 of them have to stay back and hold down the fort, the rest are deployed to support vaccination efforts. As the volunteer pool expands, they are trying to free up the Board of Health employees to go back to their assigned functions, although there are tasks that will remain CCBH responsibilities in perpetuity.

How does a person get their arm in front of a vaccinator, anyway? Each state/region/locality is receiving a certain allotment of one or the other (or both) vaccines periodically. They know how much vaccine they are getting a relatively short time in advance. The CDC has established a phased system of vaccine allocation, but the individual states are deciding who is eligible for vaccination and when.

Phase 1a here encompasses healthcare personnel who presumably are coming in contact with patients and long-term care facility residents. Phase 1b includes frontline essential workers, including teachers and people 75 and older. Phase 1c is for people 65 and over, people between 16 and 64 years of age with underlying medical conditions, and other essential workers. It is inconsistent and variable between localities; my county is just easing into Phase 1b this week, whereas Florida has been in Phase 1c for weeks.

One of the biggest issues with this system is the lack of a reliable methodology for people to sign up and be notified that their vaccination opportunity has arrived. Without a standardized mechanism, eager vaccinees are scrambling, frantically signing up on multiple lists. Since there is limited (if any) interoperability, when a person receives their vaccine at one venue, other vaccination sites may continue to expend effort to invite them to get vaccinated elsewhere. For instance, my 90-year-old father, who lives at an assisted living facility, was fully vaccinated last week, but he is still getting notifications from his healthcare system that he is eligible to be vaccinated there. My in-laws, who reside in Michigan, spent five hours on two consecutive days calling around and waiting on hold before securing appointments for their vaccinations. Many who are reluctantly willing to get vaccinated are getting thwarted by bureaucracy; if the impediments are too difficult to overcome, they may abandon their attempt to secure a shot. There has got to be a better way.

If I could advise the new administration, I would suggest that they have virtual town hall meetings to allow for sharing of vaccination best practices. There originally had not been national coordination, and everyone was inventing their own wheels. One standardized practice might not suffice; what works in Cleveland at sub-freezing temperatures may not translate to Arizona or Florida. However, those states could counsel Cleveland on what to expect come summer. Is it worth doing registration electronically, and having the vaccinator review the information on an iPad, like my sister does in New Hampshire, or is it better to have paper forms and a documenter who inputs the information, freeing up the vaccinator to just vaccinate? How can you bolster Wi-Fi access? How do you provide people with information about side effects, and how to schedule the next appointment? How do you judge how much space you need per vehicle, if people are remaining in their cars and trucks? What is the best set-up for traffic flow? What are tricks to increase throughput? What are the pitfalls being run into?

Vaccinations are accelerating. Supply is increasing, demand is increasing, output is increasing. I am hopeful.

I have personally administered 295 vaccines during four events over the last three weeks. Next week, when I volunteer on Wednesday, I will get my second dose and be fully vaccinated. It will be such a relief!

If, as a society, we can hold it together a little while longer, there is light at the end of this tunnel. Wear your mask (two masks are recommended now), physically distance, don’t congregate, wash your hands, and get your vaccine when it is your turn. We are in a race with the variants; it is a race we must win.

(I recommend you check out: How a sluggish vaccination program could delay a return to normal and invite vaccine-resistant variants to emerge)

Programming Note: Listen to Dr. Remer today when she co-hosts Talk Ten Tuesdays with Chuck Buck at 10 a.m. Eastern.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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