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Why is Maryland’s COVID-19 vaccination rollout so slow? Some cite lack of central planning.

It was early Dec. 23 when 100 doses of the Moderna COVID-19 vaccine arrived in Baltimore County, and by evening half had been given to health department workers and half to first responders.

About 3,400 more Moderna doses arrived a week later, and 6,825 Pfizer doses arrived after that. They have not all been used, though appointments are scheduled to use many of them.

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“People have to understand, I can’t now just open a clinic and hope I get vaccine,” said Dr. Gregory Branch, the county health officer. “I have to plan once I know how much vaccine I’m getting.”

Baltimore County joins hundreds of other county and city health departments, hospitals and nursing homes statewide, scrambling to use the first vaccines shipped around the country. The undertaking has been massive, unprecedented — and slow.

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Maryland initially ended up at the bottom of a list of states for how slow it was using its doses. That gap is now mostly gone, with the state now having injected about 27% of its more than 371,425 doses, a hair under the national average, according to federal data. State data suggests the number vaccinated could be even higher now.

Few seem satisfied, however. Even Gov. Larry Hogan joined a national chorus of criticism. The Republican governor both threatened to take unused doses from hospitals and health departments and pledged more resources, including vaccination assistance from the Maryland National Guard. Recent federal legislation also puts about $3 billion toward vaccinations.

Observers and officials say the challenges are many, but money, planning and manpower are core impediments. With no overarching federal plan, states were left to develop their own. The American Hospital Association wrote in a letter to federal health officials this week citing “64 disparate micro-plans developed by the states, a few large cities, and other jurisdictions” that don’t appear able to achieve lofty federal vaccination goals.

States such as Maryland, in turn, left the details to hospitals, nursing homes and health departments. State data released Friday showed the health departments in Caroline and Calvert counties have used most of their allotted doses, while those in Prince George’s and Washington counties still have used next to none. The state’s hospitals have used between 30% and almost 92%.

“The fundamental problem across the country is there has been really inadequate preparation and planning and inadequate support to the states and local jurisdictions to conduct a mass vaccination campaign,” said Dr. William Moss, executive director of the Johns Hopkins International Vaccine Access Center.

Despite a massive investment in developing vaccines, Moss said, “somehow there was the mistaken assumption that all the federal government needed to do was deliver a vaccine to states and everything would go smoothly.”

Moss said local health departments and hospitals are slammed with patient care and testing and not only lack staff for vaccinations but the ability to quickly hire and train new workers. And they receive little notice about how many doses they will get from federal reserves.

Several states with similar-sized populations are outperforming Maryland in both total doses and rate of vaccinations, including Tennessee and Massachusetts.

Moss speculated that big, local institutions might be hampering their progress by somehow “overthinking” or hewing too closely to their own prescribed priority subgroups. After a plodding start, data released Friday shows the state’s larger systems — Johns Hopkins Medicine, the University of Maryland Medical System, and MedStar Health — have used about half of their doses.

Looser rules have led to long lines of seniors in Florida and potentially random injections elsewhere, trade-offs that others agree may be less likely to reduce COVID-19-related hospitalizations and deaths.

“You want to be very methodical with scarce doses,” Baltimore County’s Branch said, “to get vaccines in the right arms.”

But some local health departments have struggled to vaccinate anyone.

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Baltimore City had used just over 2% of its doses by Tuesday, but that rose to about 21% by Friday after officials opened a clinic at Under Armour’s Port Covington campus.

The Washington County Health Department hadn’t reported using a single dose of its vaccines by Friday, with officials saying its staff was needed for COVID-19 testing and tracing in the hard-hit jurisdiction. Department spokeswoman Danielle Stahl said the county would partner with a local hospital to vaccinate first responders and seek state help to do more.

“We plan to provide additional clinics in the community and use every resource available to us to ensure all eligible individuals who want the vaccine will have access to receive it,” she said.

Smaller counties, however, do have some advantages. Rural Caroline County on the Eastern Shore has about 30,000 residents, compared with about 870,000 in Baltimore County, and has used nearly all of its 1,100 allotted doses so far.

Laura Patrick, the Caroline County health officer, said agencies there were able to collaborate on a clinic in the conference room of a county building.

“We just are so small that everybody knows everybody and for me that is such a help because I don’t have a lot of different agencies and providers,” said Patrick, a nurse who is helping administer the vaccine.

Hospital systems in Maryland, however, tend to be large, complex operations. They are trying to vaccinate workers between long shifts tending to COVID-19 and non-COVID patients. A record 1,885 people were hospitalized Friday in the state with the coronavirus, 447 in intensive care units.

According to state data, hospital systems all appear to be ramping up their operations.

Johns Hopkins had used 54.5% of its doses by Friday, up from just over 38% at midweek, according to state data. Hopkins officials said they had injected more than 15,500 workers and about 1,480 had received their second dose. Hopkins based its plan on federal and state guidance to include workers with varying degrees of patient contact. The pool of eligible employees will expand next week to support staff.

The 13-hospital University of Maryland Medical System had used about 46% of its doses by Friday, up from 38% reported Wednesday. System officials said they have hosted more than 125 clinics and more than 15,000 employees were expected to be vaccinated this week. The system has 25,000 employees and 4,000 affiliated physicians.

Michael Schwartzberg, a system spokesman, said officials are working quickly, but there are logistical issues such as time needed to monitor vaccinated employees. Injections need to be staggered in case of adverse reactions.

Staff is a huge issue, as well, as “staff who have clinical care responsibilities are the same individuals who are administering the vaccinations, a challenge when hospitals are facing a patient surge and high census levels,” he said.

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Sharon Boston, spokeswoman for LifeBridge Health, said the two-dose regimen also is a challenge. The Moderna vaccine requires a second dose at 28 days and the Pfizer vaccines requires one at 21 days. LifeBridge was scheduling both appointments at the same time, though there were initial concerns about receiving enough doses on the appropriate timeline at each system facility, which includes Sinai, Northwest and Carroll hospitals and Grace Medical Center.

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“We are now vaccinating a steady number of employees each day and continue to tweak our process, as needed,” Boston said.

At nursing homes, where residents and staff are being vaccinated, there are even more hurdles, such as the large number of facilities.

Many residents rely on family for medical decisions, adding a layer of paperwork, said Joseph DeMattos, CEO of the Health Facilities Association of Maryland. Many nursing homes in Maryland also care for a continuous cycle of patients rehabilitating after a hospital stays, making scheduling difficult, he said.

This week, the state data showed that 227 nursing homes had used less than 14% of their allotted doses, though DeMattos said the number was closer to a quarter due to a reporting lag. The pharmacy chains conducting clinics under a federal contract were given 72 hours for reporting, though Hogan said he would reduce that deadline to 24 hours.

Some nursing home workers have been hesitant to get the vaccines, which were tested for safety and efficacy in record time. About 85% of residents were willing to be vaccinated but only an average of 55% of staff were willing during the first of three clinics at each center.

The rest, “do not want to be first,” DeMattos said. “There is every expectation that it will get better over time.”

CVS Health, among those running the clinics in nearly every state, defended the rollout.

“We’re dealing with a vulnerable population that requires on-site and, in some cases, in-room visits at facilities with fewer than 100 residents on average,” CVS President and CEO Larry J. Merlo said in a statement. “Despite these challenges we remain on schedule, and the number of vaccines we administer will continue to rise as more facilities are activated by the states.”

But in West Virginia, which opted out of the federal contract with CVS and Walgreens to handle nursing homes, vaccinations have been completed.

Tinglong Dai, an associate professor of operations management and business analytics in the Johns Hopkins Carey Business School, said the pharmacy-led program has “turned out to be unacceptably inefficient.” West Virginia, he said, relied on a network of local pharmacies that outperformed.

The performance will be important going forward as states and federal officials already say they will rely on pharmacies to vaccinate residents in the next priority groups, expected to begin in late January.

Dai said there are good models for efficiently distributing vaccines, including one mimicking Amazon fulfillment centers. In that scenario, states would open warehouses to serve large populations of a county or metro area and federal officials would deliver vaccines there. The warehouses, in turn, would deliver to distribution sites such as hospitals, clinics and pharmacies on a daily or weekly basis depending on demand so doses don’t go unused.

A central portal would be needed for people to verify eligibility and find vaccines, as well as get reminders and schedule second doses. Dai also said there should be a hyper-local “standby list” to insure all doses are used.

This week, Hogan said the state expects 10,000 doses to arrive a day for “the foreseeable future.” Absent increased production and purchase by the United States, or approval of another vaccine, that means the state could vaccinate about 30% of the population by the end of May.

Officials say the real test of the vaccination system will come as larger groups of people become eligible. The next phase is expected to begin in late January and include those age 75 and older and essential workers in schools, government and other areas.

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