Dr. Dora Anne Mills

Not-So-Brief COVID-19 Update by Dr. Dora Anne Mills. Originally published Sunday, January 10, 2021.

We are witnessing two turbulent transitions of power. First, are the violent eruptions sending seismic ripples across the bedrock of our democracy. These last few days I am reminded of how tremulous I felt in the wake of the 9/11 attacks, and the sense of instability and concerns about where the next attacks may come from. However, those were international terrorists. Today, we’re threatened from within the country.

Second, are the pandemic eruptions. The virus is wielding its deadly power, with the U.S. having lost one in 1,000 to the disease in less than a year, and we are in the fight against time to vaccinate as many people as quickly as possible. With vaccines, we have some hope to wrestle power over this pandemic and take back our lives.

Ramping up vaccinations

A number of you are asking what is taking so long to ramp up vaccinations? Here is my take on the situation. In countries with a universal health system, the system’s workforce is deployed and vaccines are administered and entered into a nation-wide electronic system. Although there are advantages and disadvantages to different healthcare systems, one disadvantage to ours is the inability to quickly ramp up such efforts as some other countries can do.

Across the U.S., public health agencies, hospitals, and health systems, health centers, and other providers have different electronic medical record (EMR) systems. They make up a crazy patchwork quilt of systems. Each of them is working tirelessly right now to build into their systems the ability to schedule people for the COVID vaccine, to register people who are not their patients, to load information into the state’s immunization information systems (IIS, which is ImmPact in Maine), and to enter insurance information for vaccine administration reimbursement. These systems were not built to identify patients by what type of work they do (e.g. being a health care personnel or another essential worker), so direct outreach to these populations is very limited. The federal requirements for information that must be submitted within 24 hours of a shot being given to the IIS are substantial, and this is very different from influenza and other vaccines. These reporting requirements are understandable, since these are new vaccines against a new disease, so it is important that information is tracked.

Time lag

Why do these systems take so long to launch, and why didn’t they get built earlier? Some of these requirements are specific to the two current vaccines, the details of which we learned in mid-late December when they were approved. It also was unclear until recently what would be expected of providers versus what responsibilities would be taken on by federal, state, or local governments. What has been shocking is the billions of federal funds spent on the research and development of vaccines, with none for the systems and workforce needed to administer them.

Additionally, most states have public health agencies that regularly deliver care, including vaccines. Strapped for funds and overstretched by the pandemic surge, they are very challenged to build the systems needed and deploy a workforce to vaccinate. In Maine and the rest of New England, our public health agencies deliver very little routine health care including vaccines. For them, they rely on their very small health care workforce, such as public health nurses, and they rely most heavily on private providers such as hospital health systems and health centers.

Normal times vs. a pandemic

During normal times and normal vaccines, clinics can be set up practically on street corners. However, with the technologies that are necessary on-site as well as requirements for storage and narrow subzero temperature ranges for these vaccines, and the delicate reconstitution of one of them (Pfizer), current COVID-19 vaccines must be administered in certain types of settings. Because of the pandemic, these sites must be quite large, to allow for appropriate distancing, including for those vaccinated to sit at a distance for the required 15 minutes post-vaccine.

Implementing all of these requirements is taking place during the worst surge of the pandemic, with unprecedented demands on the health workforce. I am sure I can speak for other health systems and providers when I say that we are extremely grateful for the many volunteers who have stepped forward. Even with volunteers, we need staff to coordinate and schedule the volunteers, stay in touch with them, respond to their questions, and requests for scheduling changes. We need staff to train volunteers, including training them in privacy laws and infection control practices. We need staff to check volunteers’ credentials, such as their licensing status and background checks. With that said, we’re still very grateful and are working hard to set up the appropriate support systems for volunteers.

Vaccine availability

The unpredictable vaccine supply chain is also a major constraint. Across the country, states and providers are not sure how much vaccine will be available from one week to the next. Ramping up and shrinking clinics on a weekly basis in response to vaccine supply has been commonplace.

Be assured there are people across Maine and across the country who are working tirelessly on the myriad logistical challenges to stand up more mass vaccine efforts. One of the advantages of our country’s health system is the variety of health care and public health systems that reflect local styles and priorities. However, during a pandemic, mobilizing a large number and variety of electronic systems and workforces with the information reporting requirements and pandemic-driven requirements is daunting. The good news is those systems are launching. I hope in the coming weeks that the vaccine supply will also be more stable and plentiful.

A race against time

As I read reports on pandemic activity, listen to daily reports of my colleagues, and learn of serious illness or deaths of people I know from COVID, I realize we’re in a race against time against this virus. And I know vaccine is our most likely ticket to stability.

As we witness the challenges our country faces in the vaccine race to stability, we’re also witnessing the other transition to power. While our country is a melting pot of health care and public health systems, it is also a melting pot of people and ideologies. Normally, this variety is our advantage, but we are currently witnessing the disadvantages as well – when the variation slows the launching of the vaccine weapon against the pandemic, and when the variation allows voices focused on disrupting the country.

Threats and transitions

I hope that as we heal from both seismic events – the pandemic and the threats to our democracy – that we continue to embrace our diversity. However, I also hope we further discern what the guardrails should be. What should be standardized in order to protect the overall health of our country? What electronic health systems should be the same across the country? How can we assure an adequate and appropriate health workforce across the country to respond to public health and health care crises? How do we continue to embrace diverse ideas and voices, and what should the boundaries of those be?

And most critically, how can the country with reportedly the best health care system in the world have the highest number of pandemic deaths in the world and be sluggish at launching the best weapon we have against the pandemic – vaccine? How can the bedrock of the oldest and most diverse democracy in the world be shaken by such a seismic event as we witnessed this last week? These are the questions we must answer for the current as well as for the next pandemic and threats to our democracy.

Dora Anne Mills, MD, MPH, FAAP, Chief Health Improvement Officer, MaineHealth