Oregon trails
On the state’s lagging vaccine performance and lost doses
According to the COVID vaccine tracker maintained by Bloomberg, Oregon has administered only about a quarter of its vaccine inventory. That puts us near the very bottom of the country, ahead of only four other states. This week, the Oregonian also reported that one of Oregon’s health providers had allowed twenty-seven of those doses to go to waste because it was unable to find eligible healthcare workers to receive them. Twenty-seven doses is a tiny fraction of the state’s allocation, but every expired vaccine that goes into the trash instead of someone’s arm is a potential policy failure, so I was curious about how this happened and whether it’s likely to occur in the future.
First the good news. From initial reporting, it wasn’t clear when the loss occurred. I reached out to Brian Terrett, director of public relations and communications for Legacy Health, for more details. He informed me that this happened early in the vaccination effort when it was assumed that every vial of the Pfizer-BioNTech vaccine would contain only five doses. As known now, they often contain enough for six or seven. Legacy had also staggered vaccinations of frontline workers as a precaution to ensure that side effects would not result in excessive absences.
As a result, Legacy ended up with more doses than available patients in the brief window before the doses expired. On net, however, “having six or seven doses in a vial has allowed us to vaccinate almost 700 more people than we were allocated,” says Terrett. “For every expired vaccine, Legacy vaccinated almost 25 more people than we expected with our given allocation.”
Based on the above, it’s difficult to fault Legacy for losing a few doses of a very fragile vaccine early in an unprecedented effort. I am still worried, however, that situations like this will occur in the future and that the Oregon Health Authority’s strict eligibility guidelines will lead to additional vaccines going to waste.
We know from other states that this is a real possibility. The New York Times reported today on doses being thrown out when the city health department refused to allow a clinic to vaccinate outside of initially eligible groups. Meanwhile, hundreds of thousands of additional doses languish unused for a lack of healthcare workers stepping up to take them and rigid regulations against allowing them to go to anyone else.
Other jurisdictions have taken a more open stance to ensure that vaccines do not go to waste. In Israel, which currently leads the world in vaccinations, providers have been known to simply call people in from the street to receive near-expiration doses. The same is occurring in Washington, DC. In Northern California, one hospital found itself with nearly 600 doses about to spoil due to a broken freezer; setting state health eligibility guidelines aside, the hospital managed to get every single one of them into a human arm before they were lost.
The lesson of such incidents is that no matter how carefully you plan, situations will likely arise in which vaccines that are on the verge of expiration need to be administered right away. And when they do, health providers need the flexibility to administer them to anyone available, even if they don’t fit strict eligibility guidelines. In Oregon, they are not currently allowed to do so.
Much like New York, Oregon follows complex guidelines determining the order of vaccination. Prior to this week, vaccines were limited to individuals in “Phase 1a, Group 1.” On Monday, in recognition that the state was lagging behind, this was expanded to include “Phase 1a, Groups 1–4.” (You can look up the details here, but these groups mostly consist of healthcare workers.) This is better than nothing, but it’s far from the kind of flexibility that would allow for pulling in a pizza guy or a Lyft driver when a vaccine is about to expire.
For contrast, it’s worth looking to Connecticut. The state has delivered 53% of its vaccine inventory, more than double Oregon’s 25%, and is among the country’s leaders for vaccine administration. Writing at Medium’s COVID-19 blog, Alexandra Sifferlin attributes much of this success to flexibility:
Perhaps one of the most important factors is that the state’s plan allows for some flexibility in who qualifies for a vaccine, prioritizing getting shots into arms over strictly following a preset roadmap for how vaccines will be distributed.
To prevent doses of the vaccine from going unused, which is happening in many states, [Connecticut Gov. Ned] Lamont said on Monday that Connecticut developed a “just-in-time inventory” system where unused doses of vaccine at a given location can be transferred to other facilities where there is demand at the end of the day. The Connecticut Department of Health has said to prevent vaccines from being wasted, vaccination providers should have a waitlist of people they can call in ASAP if they have leftover vaccine doses.
In response to questions about whether Oregon is allowing any flexibility to ensure that near-expiration vaccines are not wasted, a representative of the Oregon Health Authority told me that “[the] most important priority right now is to get as many people in Phase 1a vaccinated as possible.” Similarly, in a press briefing on Monday, OHA director Patrick Allen was asked about vaccinations going to healthcare workers who don’t deal directly with patients. “We’re providing some very direct guidance out to vaccinators that we are still in category 1a and that we shouldn’t be moving on to people who don’t have patient exposure,” he said.
I also asked Brian Terrett at Legacy Health about whether his organization would be free to administer vaccines to individuals outside the state guidelines if a situation were to arise again in which doses were in danger of expiration. “The OHA has reiterated that, in Phase 1A, vaccines are only supposed to [go to] front-line healthcare workers,” he told me.
Perhaps in an ideal world, Oregon would perfectly execute delivery of vaccines to each phase and subgroup in an efficient and orderly fashion, ensuring that each dose goes exactly where it will make the greatest impact. The state is falling far short of that ideal, however, and it’s certainly worth asking whether we would be better served by less rigid adherence to eligibility requirements and more focus on simply getting shots into arms. The Surgeon General has specifically warned that guidelines are often slowing down the effort in the United States; see also this excellent column by Virginia Postrel.
The state is focused on equity and ensuring that the rules are followed, both of which are noble goals, but a vaccine in someone’s body does much more for public health than one that’s stuck in a freezer or thrown in the trash. At the very least, I hope the Oregon Health Authority will prepare for another situation in which near-expiration vaccines need to be administered quickly; the state should communicate to health providers now that diverging from guidelines is better than letting those doses go to waste. This is an emergency and we should treat it as such. The possibility of vaccines going to waste due to lack of flexibility is foreseeable, and this is no time for letting the perfect be the enemy of the good.
