Please Note

The Washington Post is providing this important information about the coronavirus for free. For more free coverage of the coronavirus pandemic, sign up for our Coronavirus Updates newsletter where all stories are free to read.

Securing an appointment for a first dose of the coronavirus vaccine might feel like a victory.

But then there is Round 2.

Scarce supply of the Pfizer and Moderna vaccines has stirred anxiety about whether the required second dose will be available. Different protocols in different jurisdictions — as well as several mishaps in recent weeks — have added to the frustration and concern in the greater Washington region.

Officials in Prince George’s County are so worried about a shortage of second doses that they held some first doses in reserve, slowing the pace of vaccinations — even though the federal government now automatically schedules its second-dose shipments. In Anne Arundel County, a data error temporarily disrupted shipments, forcing the abrupt cancellation of two second-dose clinics this month. In Harford County, a second-shot clinic was partially derailed by hundreds of residents trying to get their first shot.

“The system has been so disordered and chaotic that it’s led to panic,” Maryland state Sen. James C. Rosapepe (D-Prince George’s) said in a hearing last week.

In Virginia, too, providers until a few weeks ago were unsure there would be enough vaccine to give second doses, state vaccine coordinator Danny Avula said, leading them in many cases to also set some first doses aside.

Pfizer doses should be administered 21 days apart and Moderna 28 days apart, although the Centers for Disease Control and Prevention said last month that second shots can be scheduled up to six weeks later if needed.

The federal government sends second doses to states on a schedule based on when first doses go out the door — not when the shots are put into arms. In Maryland’s system, that means second doses can sit unused for two weeks. A slow use of first doses can result in an even larger glut of second doses shipped and waiting to be used.

Rosapepe and some other Maryland lawmakers are urging the state to reduce the glut of second doses, perhaps by using some of them for people seeking their first shot. They note the strong demand for vaccinations and the fact that, according to a recent analysis by the Department of Legislative Services, Maryland has consistently had a higher share of yet-to-be-used doses than most other states.

“A dose sitting on a loading dock is not a second dose by any measure, except the Maryland health secretary is calling it that,” Rosapepe told acting health secretary Dennis Schrader at last week’s hearing. “Hoarding doses for three or four weeks just isn’t good public health policy.”

But Schrader defended the practice, noting each second dose is specifically paired with a first dose: “When we give a first dose to an individual, we feel ethically compelled to make sure that person gets their second dose.”

Schrader said using doses earmarked as second shots to provide people with their first shots could gum up the flow of doses later, potentially creating a shortfall.

In Virginia, Avula said the decision to hold first doses in reserve led to a backlog of 360,000 second doses.

In a process he compared to “air traffic controlling,” Avula said officials are using spreadsheets to figure out how they can get doses out most efficiently. They have directed six health districts to use second doses as first doses.

Part of the confusion in Maryland stems from health departments having different strategies for scheduling second-dose appointments — a decision the state deliberately left up to localities.

Some do it on the same day residents receive their vaccines, while others wait until closer to the day the second shot is administered. The hospitals, pharmacies, mass vaccination sites and other providers also administering shots have made their own scheduling decisions.

Missing batches of second doses were the reasons two second-dose clinics were canceled in the county this month, Health Officer Nilesh Kalyanaraman said. People with appointments on those days were rescheduled for later clinics.

Bryan Mroz, the state’s incident commander for the vaccine rollout, said a team of forensic data analysts and certified public accountants identified the error as a federal mistake, which delayed the shipments. It has since been fixed.

“It is unclear to me where the issue was,” Kalyanaraman said in an interview. “We hope this is a one-off.”

Nancy Carr, a spokeswoman with the state AARP, said senior citizens across the state have expressed a mixture of disappointment and frustration during town hall meetings.

“People are very concerned with the supply so low,” Carr said, “will a second dose be available?” She said it is important for seniors’ peace of mind that second-dose appointments be scheduled at the same time first shots are administered.

But officials in Montgomery County, the state’s most populous jurisdiction, say they have been able to avoid cancellations partly because they do not schedule second-dose appointments when giving first shots. Instead, they send residents an email four to seven days before their second dose is due, directing them to a website where they can make an appointment.

The process has also gone smoothly in Howard County, where health department staff use iPads to help seniors sign up for their second appointments during the 15 to 30 minutes in which they wait in their cars after their first doses.

Health Officer Maura J. Rossman has instructed staff not to slow the administration of first doses. “We don’t need any more difficulties,” Rossman said. “I’ll take this as a win.”

A different reality is playing out in Prince George’s, which has reported the lowest percentages in the state for both residents receiving their first dose and residents receiving both shots.

County Executive Angela D. Alsobrooks (D) said during a tele-town hall Saturday that residents who received first shots had difficulty securing second-dose appointments because the links for sign-ups were shared widely, leading appointments to be filled by people seeking first shots.

Starting this week, all residents will receive the times for their second appointments at the same time as their first to minimize confusion.

Prince George’s has consistently ranked near the bottom of the state in terms of percentage of first doses its health department has used. That’s partly because the county made a policy decision to hold back first doses due to concerns about second-dose supply, Health Officer Ernest Carter said.

This week, the health department dramatically sped up the administration of first doses — and gave 750 to hospitals.

Alsobrooks tweeted Thursday that the county may have to cancel appointments Friday and this weekend because a shipment from the state will probably be delayed by weather and the county only has 573 remaining first doses. She said second-dose clinics would continue as scheduled.

Frustrated lawmakers have been urging the health department to speed up, concerned the county will get fewer doses if the agency does not do a better job of getting the doses it has out the door. Mroz said the state has “asked all providers to get all first doses as fast they can. We do not want any first doses sitting the on the shelf.”

The various responses between and within states when it comes to every step of vaccine distribution — including decisions about second doses — are “the ripple of poor planning” by the Trump administration, said Neil J. Sehgal, an assistant professor of health policy and management at the University of Maryland School of Public Health.

“There wasn’t a plan in place, so local jurisdictions have had to build this over and over again,” he said. “We say that all public health is local, but that is not the best way to do it all the time.”

In Harford County, as in Prince George’s, the health department slowed the administration of first doses to make sure there were enough second doses, said Health Officer David Bishai. The department will administer no more than than 6,000 shots in February, Bishai said, compared with 8,000 in January.

“You had to slow down to catch up with yourself,” Bishai said. “We are all tracking out where doses are and thinking together.”

He said an additional challenge was that residents who received their first dose were sharing the link to sign up for second doses with their friends and loved ones. The health department staff then had to remove hundreds of people seeking first shots who showed up at a second-dose clinic.

“We had to go back and find the first-dose people,” Bishai said, “and say, ‘You don’t belong here.’”