Across the United States, a decentralized public health system created logistical challenges for vaccine delivery that countries such as Israel and the United Kingdom were able to avoid. The federal government left the task of getting shots into arms to local and state bureaucracies, public health experts say, and didn’t provide the necessary resources.
Regional leaders also could have prepared better-functioning registration websites and distribution networks.
And perhaps more crucially, said Immunization Action Coalition Deputy Director Kelly Moore, elected officials could have done more to manage the expectations of a pandemic-
weary public. By changing eligibility guidelines prematurely or without adequate explanation, experts said, local officials in the D.C. region and elsewhere added to the confusion.
“This was always going to be the most complex mass vaccination program in human history. The fact that we have faced challenges shouldn’t surprise anyone,” said Moore, whose organization advocates for safe and efficient immunization programs. “But the public could have been much better served if it had been given a more realistic set of expectations.”
An “immunization enterprise” typically consists of three main players, Moore said: researchers and manufacturers who produce the vaccine; regulatory agencies that approve the vaccine; and clinicians who administer it.
Although the Trump administration invested an extraordinary $14 billion to develop a vaccine, it didn’t match that investment in the state and local health departments preparing to receive and administer the shots, she said.
Earl Stoddard, Montgomery County’s head of emergency management, said the county started planning for the vaccine last summer but was surprised by the lack of federal guidance on issues such as distribution, storage and delivery — which left individual states and counties to develop their own processes.
“Was it always going to be hectic? Yes,” he said. “Did it have to be as hectic as it is? No.”
The region’s governments made plans and then changed them in a matter of weeks. In the District, for instance, Health Director LaQuandra Nesbitt said in mid-February that the city would vaccinate 70 percent of senior citizens before opening appointments to younger people with health problems. The next week, with barely half that many seniors vaccinated, Nesbitt announced people 16 and older with health problems could get vaccines starting March 1.
When the registration website and phone lines opened to those younger people last week, tens of thousands were vying for about 4,500 appointments, and the system crashed three days in a row.
The city hastily implemented some fixes that technical pros had been calling for, including a waiting room to enter the website. Thursday’s sign-ups went more smoothly — although all 4,622 appointments available online were claimed in just 6 minutes 48 seconds, according to Deputy Mayor John Falcicchio. On Friday, frustrated residents reported more glitches.
This week, the city will scrap the whole system in favor of a new approach, more similar to a waiting list — although D.C. Council members were alarmed to learn at an oversight hearing Thursday evening that the vendor for the new system had not yet been finalized.
Many a website designer could have foreseen the problems and designed a better system from the outset, said Alexander Howard, who runs the Digital Democracy Project. “There have been billion-dollar companies based on removing friction between you and whatever is the thing you want to do,” he said, noting that the problem of signing up for a vaccine online isn’t so different from challenges that Web designers solve daily.
“The lesson from the last decade of failures [of government websites] — and the failures are vast — is that how they build and buy software, it has to be different from how you build and buy physical things like tanks or planes or buildings,” Howard said. “You have to have the geeks at the table from the beginning.”
Many jurisdictions also did not anticipate how inconsistent the supply chain would be, said University of Minnesota public health professor Rebecca Wurtz. Governors and mayors based their projections on President Donald Trump’s promise to provide more than 40 million vaccines by the end of 2020 — a goal that immunization experts were skeptical of, and that the government didn’t meet.
“We overpromised and underdelivered, when we should have underpromised and overdelivered,” Wurtz said.
Something similar happened during the vaccine rollout for the swine flu in 2009, albeit on a less memorable scale. Like with the coronavirus, the Centers for Disease Control and Prevention first authorized a seasonal flu vaccine, then a rapidly developed pandemic vaccine later in the same season. Officials promised doses, only to find them in short supply because of production delays. In Maryland, like many other places, cities and counties canceled clinics and people waited in lines that stretched for hours.
Ultimately only about 27 percent of Americans ever got the H1N1 shot. In later years, the H1N1 vaccine was incorporated into the regular one-dose seasonal flu shot.
“There’s a tremendous desire to please the public, reassure the public, and in times of uncertainty, hope for the best,” said Moore, who led Tennessee’s immunization program during the H1N1 crisis. “But it’s led again to this situation, where people end up being incredibly frustrated.”
Changing eligibility requirements can contribute to the problem, said Raphael Lee, director of U.S. Digital Response, a volunteer-driven organization that provides tech support to local governments. Many jurisdictions outsource digital projects to vendors, Lee said. When vaccine eligibility guidelines change, the sudden spikes in traffic can trip up the vendors, who are caught off guard. “The shifting guidelines and the phased approach makes the technology project a moving target,” he said.
Lee’s organization is urging governments to ensure that their vendors conduct adequate “load testing” to prevent scheduling websites from crashing when thousands of newly eligible people search for vaccine slots.
Another mistake, Lee added, is that with certain notable exceptions, many governments have chosen a decentralized approach to vaccine distribution, allocating doses to pharmacies, hospitals and local health departments. Leaders in Maryland, which has the most decentralized approach in the region, say this prevents a “single point of failure.” But it also allows multiple, sometimes similar tech glitches to emerge in disparate systems, Lee said. These governments, he noted, have centralized data on where there are doses, but not where there are appointments.
“That data needs to be in one place for [scheduling] to be an easy and tractable problem . . . and it isn’t,” Lee said.
Virginia recently switched to a centralized system but still has been deluged with complaints about where people are in the line.
John Colmers, a former Maryland secretary of health who oversaw the state’s H1N1 vaccination program, said a centralized scheduling system could have been easier for residents, but it’s unlikely that it would have been foolproof, either.
The searing impact of the coronavirus on Virginia, Maryland and the District — with more than 1 million cases and 18,000 deaths to date — means that the hopefulness of the vaccine was always going to be tinged with desperation, he said.
“I just don’t think you can point to a particular approach that would have solved all the challenges,” he said.