In the four weeks since a Charlotte doctor became the first in the state to receive a shot of COVID-19 vaccine, federal officials have shipped nearly 1 million doses of the drugs to North Carolina hospitals, long-term care facilities and public health officials.
Yet most other states managed to roll out the vaccine more quickly than North Carolina, which has so far administered only about one-third of its allotment. That speed matters, as federal officials have said future distributions may be based on how quickly states are putting shots into arms.
But exactly why North Carolina lags behind is complicated.
A survey of dozens of county health departments across the state by the N.C. Watchdog Reporting Network shows a range of problems that have hampered their ability to vaccinate people in the first phase of the rollout — namely front-line health workers and the elderly. Problems include:
- The public health workforce in many counties is stretched thin.
- Social distancing guidelines and facility size limit how many patients health care workers can see at a time.
- A new vaccine management system launched by the state has made record-keeping more complex.
- And planning has been difficult – both for the state and county health departments – because they learn how many doses they're getting only week to week.
Some health directors also noted slowdowns over the holidays and some hesitancy to take the vaccine among those in the Phase 1 groups.
"I don't want to be a Negative Nelly, but I would hope people would be patient with us," said Karen Lachapelle, Edgecombe County health director. "As a whole across the state, we're all doing the best we can. In my 28 years, we've never dealt with something this big."
As the N.C. Department of Health and Human Services ramped up its vaccine distribution, Secretary Dr. Mandy Cohen put an emphasis on equity. She wanted to make sure at least some doses got to all 100 counties in the state.
But not all health departments have the same capacity to carry out the final step. As a result, some counties told DHHS they would be OK taking smaller shipments, while other counties will see their allotments increase.
Cohen acknowledged the emphasis on geographic equity contributed to the delay. Now, the state will push for speed.
"There is a tension between speed and equity," Cohen said. "And we were trying to find that right middle ground."
The federal government has distributed about 850,000 doses to North Carolina as of Wednesday, data from the Centers for Disease Control and Prevention show. That figure includes roughly 120,000 doses allocated but not yet arrived in the state, and 165,000 doses dedicated to long-term care facilities.
Providers have given initial doses to about 267,000 North Carolinians, which amounts to 31% of allocated shots.That rate ranks North Carolina 37th out of 50 states, according to the CDC's Covid Data Tracker, right behind Wisconsin and South Carolina.
Texas, Florida and New York – states allotted nearly twice the doses as North Carolina – have all administered a higher share of their vaccines than the Tar Heel State. And West Virginia has so far managed to administer nearly 70% of its dosages.
Accounting for a vaccine regimen that includes two doses per person and involves vendors, hospitals and local health departments across these jurisdictions makes exact comparisons difficult; and the standings change week to week, if not day to day.
State health officials announced this week they were setting up 10 "high-throughput" sites around the state which will receive a combined allocation of 45,000 doses. Cohen said these sites plus higher efficiency from county health departments will eat through the backlog of doses.
But as more doses of the vaccines roll in, local health officials say they're continuing to work through problems on the ground as they execute the largest mass vaccination program in U.S. history.
"It's one thing to make a plan," Pam Brown, Lenoir County Health Department director, said. "It's another thing to operationalize it, and operationalize it when you have such a difficult environment."
Dosage Allocation Issues Hamper Planning
Health departments across the state say one of the biggest factors complicating the rollout of the vaccine is the supply. But it's not just about the limited number of doses.
Federal officials announce the supply allocated to each state weekly, normally by Tuesday. State officials then divvy up that number across counties and alert local health departments, which expect to receive their shipments early the following week.
That week-to-week notice, several county health directors said, makes it difficult to plan. You can't easily tell people to sign up for vaccination appointments next week if you don't know how many shots you'll have.
"It's not like the state can say to us, 'For the four weeks in January, we're going to send you 200 doses a week,'" Brown said. "They've got to wait for their weekly allocations from the federal government."
And once the allotted doses are in hand, adjusting the size of vaccination clinics up or down takes time.
"I think sometimes people look at that and say, 'Wow, look, there's a ton of doses you guys are sitting on,'" said Ryan Jury, COVID-19 vaccine clinical liaison for Wake County public health. "But the reality is we may have gotten that dose within 24 to 48 hours, and it just takes us a minute to be able to scale up operations to meet that demand."
Local health officials also have to plan clinics with enough space to keep patients and staff socially distant and build in time to monitor patients for up to 30 minutes after they receive their shot.
"You cannot have a waiting room full of people. From start to finish, one person can take upwards of an hour to complete. That is not quick," Graham County Health Director Beth Booth said.
The limited supply of vaccine itself is also a problem.
Census estimates put the total number of people 75 and older in North Carolina at upward of 650,000, a count that includes those living in long-term care facilities. Many counties are also still in the process of vaccinating the more than 140,000 front-line health care workers as part of the first phase of the rollout.
The number eligible to be vaccinated grew even larger Thursday morning after Gov. Roy Cooper announced an expansion of Phase 1b of the program to those 65 and older, consistent with federal guidelines just released this week.
For some counties, that will mean significant portions of their population are eligible, but the doses simply aren't there.
"You're looking at about one third of our population in Brunswick County," said Brunswick County Commission Chair Randy Thompson. "Our health officials have followed the state guidance and the state plan. We just need to make sure that we have the additional doses coming in."
When 800 spots were opened in Buncombe County on one recent day, they were filled in 90 minutes.
"Next week, as soon as we get confirmation of our doses, we'll do the same, but by scheduling as many people as possible now, we can give our community some peace of mind while waiting for larger quantities of vaccine from the state," county communications director Lillian Govus said.
Elaine Russell, Transylvania County health director, said her county hasn't yet received enough vaccine to offer it to everyone eligible. She said there's been frequent communication between local and state health officials.
One of the issues, Wayne County Health Director Dr. Brenda Weis says, is a lack of control over execution, coupled with "intense state oversight without state funding."
"It is remarkable that while COVID-19 is the primary issue for voters, there is no parallel commitment to fund local health departments that are at the center of so many critical COVID response activities," Weis said in a statement last week.
Computer System Causing Problems For Rollout
Again and again in interviews with local health department officials, the topic turned to issues with the state's newly launched Coronavirus Vaccine Management System, commonly referred to as CVMS.
Developed at a cost of at least $1.2 million specifically for the vaccine rollout, CVMS was intended to be a cloud-based system for sharing data "across providers, hospitals, agencies, and local, state, and federal governments on one common platform," according to DHHS.
The state chose to build its own system instead of using the one developed by the federal government. Cohen said her department opted for its own system in order to be able to make ongoing improvements and because the federal option didn't interface with private hospital records.
But several health directors said the system isn't quite working as planned.
"The CVMS system was not designed with mass vaccinations in mind and has been a hurdle," said Rowan County Health Director Alyssa Harris.
Trey Wright, director of the Rockingham County Health Department, noted that the process of vaccinating people is delayed by the considerable time it takes to enter data for each patient into the CVMS database.
Fred Thompson, director of the Anson County Health Department, echoed those concerns.
"It is labor intensive for the local Health Department staff to manually upload each person into CVMS, which is what we have to do right now," Thompson said in an email.
Although she said DHHS has been "excellent" at communication with local health departments, Wayne's Weis said CVMS "is probably the biggest hurdle" for counties during the vaccination process.
"The state's CVMS is not fully functional, despite being several weeks into the vaccine delivery and this has been a serious impediment to registering, attesting eligibility and tracking vaccine receipt and delivery," Weis said. "Health Department staff spend many hours a week contacting the state's COVID Help Desk."
In counties like Edgecombe and Transylvania with spotty Internet access, health officials now take patient information down on paper and enter it into the system after vaccinations are complete.
"It has taken a significant amount of staff time to access and learn this new software, and we have been experiencing technical issues with connectivity that have required us to develop paper-based workarounds," Russell, with Transylvania County, said.
In Hyde County, Health Director Luana Gibbs said one of her staff members was still waiting on access to the system. "We receive guidance constantly, but the technology piece of this project has been spotty," Gibbs said.
Cohen has staunchly defended the system and pointed to the more than 200,000 shots administered as proof that the system does work, though she acknowledged it could be better.
"The system is working," she said in an interview with the NC Watchdog Reporting Network Wednesday. "The issue is we want to continue to make improvements to enhance it. So it works faster, better, more efficiently."
Despite the problems, almost every county health director acknowledged that they receive ample support and communication from state health workers at DHHS, and that the agency was working to improve the system. Cohen said the state plans to roll out improvements to the system every other week.
"We're anxious for some new enhancements, improvements with all the technology," Jury, with Wake County, said. "But generally speaking, we feel very supported and have felt that our state partners have been there to help us along the way."
With Staffing Taxed, Some Counties Asking For Help
For county health workers, the massive vaccination effort comes after more than nine straight months of dealing with a global pandemic, which has in recent weeks infected and hospitalized an unprecedented number of patients.
"We have not stopped our COVID response," Mecklenburg County Health Director Gibbie Harris said in a Jan. 5 press conference. "We have just added vaccination to that."
That's taxed many in the workforce, especially in counties with limited staff. Local health directors described borrowing staff from other county departments, using volunteers and hiring temporary staff to help meet the demands.
"Our staff are stretched thin as we are both working hard to still prevent COVID from spreading, manage case investigation for new positives, and now adding on the distribution of vaccines," Harris said.
Gov. Roy Cooper announced earlier this month that he was tasking the National Guard with aiding the vaccine rollout.
But only four health departments that responded to questions from the N.C. Watchdog Reporting Network said they were using or planning to use National Guard troops in the rollout of the vaccine.
The National Guard has been assigned to Mecklenburg County since late October. They initially worked on testing. Now they will work on vaccinations, Harris said, freeing the staff for other tasks. Guardsmen are also working in different capacities at vaccine sites in Guilford and New Hanover counties as well as the Albemarle Regional Health Services, which serves an eight-county region in the northeastern part of the state.
While some county health directors said they didn't need that level of assistance yet, others said they hadn't received details from the state about the possibility of National Guard help. But several county directors said such assistance would aid their efforts to get more doses out the door.
"NC DHHS has made us aware of support from the NC National Guard to assist some areas in vaccine deployment and would welcome collaboration if that becomes available," said Melissa Bracey, spokeswoman for the Appalachian District Health Department.
'Only So Many Hours In A Day'
With the number of doses still relatively low for now, county health officials say they're looking ahead to the future – and a possible surge of supply.
"The Health Department cannot vaccinate all who are entitled alone," Teresa Ellen, Wilson County health director, said in an email last week. "When there is a larger amount of vaccine available it is our hope that all medical providers will be administering the vaccine in our community."
Union County Health Director Dennis Joyner said participation from pharmacies and others that routinely administer vaccinations would also help. Without those providers, he worries demand from the public is going to tax their capability.
"There are only so many hours in a day to vaccinate," Joyner said.
In Rockingham County, the rate of vaccinations picked up on Jan. 12, when the county offered its first drive-through vaccination clinic. All of the county's available doses were used that day.
That will likely help the county as the state tweaks its formula for doling out doses.
"The more (doses) we administer, the more we'll receive," said Wright, the county health director.
But with many counties still waiting to transition to the next phase of the rollout, how long will it really take to provide vaccinations to all who want them?
"I wish I knew," Wright said. "That's the million-dollar question."
This story was jointly reported and edited by Kate Martin, Laura Lee and Frank Taylor of Carolina Public Press; Ames Alexander and Gavin Off of The Charlotte Observer; Tyler Dukes, Lucille Sherman and Jordan Schrader of The News & Observer; Nick Ochsner of WBTV; Emily Featherston of WECT; Travis Fain of WRAL; and Jason deBruyn of WUNC.
