As Virginia struggles to boost vaccination rates, state officials face calls for more coordination

By: - January 21, 2021 12:01 am


The Lord Fairfax Health District vaccinated more than 2,000 people last week at two walk-up clinics in Clarke County. The first, on Monday, was open to anyone 75 and older. The second, on Friday, covered anyone 65 and up — as well as most of the county’s educators.

In the neighboring Blue Ridge Health District, officials are still working to finish immunizing the health care providers prioritized in the first phase of Virginia’s COVID-19 vaccine campaign. 

It’s not that they don’t have plans for the same large-scale clinics. Earlier this month, the Blue Ridge Health District opened a large vaccination site with help from Riverbend Development — a private company in Charlottesville that owns a former Gold’s Gym and Kmart space near a bus stop and the convergence of two main roads. Riverbend, along with a few other private partners, helped the district navigate the city’s permitting process to erect a 10,000-square-foot tent outside the former retail space.

Without the tent, the district would have been left cobbling together a list of potential vaccination sites in Charlottesville and Albemarle County, said Ryan McKay, the director of policy and planning for the district, which provides health services to more than 250,000 people in Albemarle, Charlottesville, Fluvanna, Greene, Louisa and Nelson. But the district hasn’t staged the same sort of walk-up events — in part because it hasn’t had the time or the staff.

“For us, I think that wasn’t going to be the best use of our resources if we’re trying to take on 75 and older and also wrap up 1a,” McKay said. “Because we’re moving so quickly — and sooner than we wanted to, to be honest — we’re dovetailing 1a and 1b. And I think it’s going to be more effective if we can be more surgical, so to speak.”

Across Virginia, there have been major differences in how much help local health departments have received from hospitals and other private partners as well as the degree of coordination. Vaccination in Lord Fairfax, which includes Clarke, Frederick, Shenandoah, Page and Warren counties and the city of Winchester, has been heavily aided by its local hospital system, Valley Health, which immunized its own employees along with unaffiliated providers in the community. District Director Dr. Colin Greene said the system has also stepped up for Phase 1b, organizing large-scale vaccination clinics at Shenandoah University’s athletics center.

“They just started it up last week and it can knock out more than a thousand doses a day,” Greene said. In Blue Ridge, there’s been collaboration with UVA Health, which has volunteered to vaccinate some independent providers and — starting Tuesday — send some of its own employees to work as vaccinators at the health district’s primary site in Charlottesville.

A worker with UVA Health moves doses of the Pfizer COVID-19 vaccine into ultra-cold storage. (Courtesy of UVA Health)

But for the past few weeks, Blue Ridge has largely been managing vaccines in Phase 1a and 1b on its own — something Greene, the Lord Fairfax director, said would be a significant challenge.

“I can imagine what it would be like if the hospital system maybe vaccinated all its own people but didn’t want to do anything more,” he said. “I’d have some 230,000 people to vaccinate and only 73 people to do it with. It just wouldn’t work.”

How extensively each of Virginia’s 35 local health districts can rely on outside assistance is one of many lingering questions as the state implements its COVID-19 vaccination plan. Dr. Laurie Forlano, deputy commissioner for population health at the Virginia Department of Health, said Tuesday that the central office holds several calls a week with community health districts, where plans are “built upon years of experience in vaccine planning and execution.” 

But VDH hasn’t developed a uniform playbook or guidance that local health departments can follow when it comes to COVID-19 vaccination — a campaign that’s logistically unprecedented. Some hospitals and local health systems have taken large roles in vaccinating their communities, but there’s no state directive or requirement that they offer assistance or coordinate with their local health departments.

Virginia, like most of the country, has struggled to quickly administer the shots amid inconsistent messaging from the federal government and shipments that arrive a week at a time — making it difficult to consistently plan how many doses VDH can redistribute. At a news briefing on Saturday, Dr. Danny Avula, who was named the state’s vaccine coordinator on Jan. 6, weeks after Virginia’s first doses arrived in mid-December, said the department got 300,000 dose requests this week but received only 106,000 doses from the federal government. That number also changed for the state mid-week — federal officials had initially told Virginia to expect up to 80,000 shots.

But data from the Centers for Disease Control and Prevention also indicate that Virginia is falling behind many other states in administering doses, which are all facing the same federal problems. As of Wednesday afternoon, Virginia was ranked 42nd out of 50 states and Washington, D.C. when it came to shots administered per 100,000 residents. And while the average number of daily new doses in Virginia has been steadily increasing (18,740 as of Wednesday morning) VDH’s public vaccine dashboard still shows a total of 360,051 shots administered out of 943,400 distributed across the state — a gap of more than half a million doses.

Accounting for that gap has become enormously complicated. After initially telling the Mercury that the state’s dashboard did not include doses reserved for long-term care facilities through a federal partnership with CVS and Walgreens, VDH said Monday that those shots are in fact included in the state’s tally of doses distributed and administered. According to Avula, that equates to roughly 226,000 shots over which Virginia has little direct control. 

As the Roanoke Times reported Tuesday, there are other discrepancies with the state’s data. Currently, VDH is showing it’s distributed more doses than the CDC reports allocating to Virginia. Health systems also say they’ve given out more doses than reflected on the state’s dashboard.

As of Wednesday, VDH reported that 175,978 shots had been administered at hospitals across the state. But the Virginia Hospital and Healthcare Association reported 234,389 on its own public database

Avula and other state officials have said that up to 200,000 doses may simply not have made it into the state’s database yet — making Virginia look farther behind that it actually is. VDH recently hired 10 new staff members specifically to work with vaccination sites and ensure data on administered vaccines is making its way to the state. 

It’s more than an optics issue, though. If shots aren’t uploaded into the Virginia Immunization Information System, or VIIS, which reports to the CDC, the federal government could cut Virginia’s shipments — a threat it’s recently made to all states.

“What I’m telling all of our providers is that I see them doing a great job, but if those shots don’t get into the system, it’s going to screw you and it’s going to screw us,” Avula said in an interview on Saturday. “Because our federal allocation is dependent on our ability to get that vaccine out.”

Dr. Danny Avula speaks at an event in 2018 during which he was named director of both the Richmond and Henrico County health departments. (Katie O’Connor/Virginia Mercury)

Escalating frustration

The vaccination effort has become increasingly politicized since the start of the General Assembly session, with Republicans criticizing Gov. Ralph Northam for the state’s response and Democrats casting the blame on an erratic federal rollout orchestrated in the waning days of the Trump presidency. Those arguments have spilled out into the House and Senate floors sessions as the General Assembly begins the 2021 session. 

Behind the scenes, though, the state is fielding complaints on numerous fronts. Seventeen city managers and county administrators in the Hampton Roads region sent a letter to Avula and state Health Commissioner Dr. Norman Oliver on Jan. 12 outlining concerns with the vaccination process. Those ranged from a request for more local data on vaccination rates and the number of vaccinators in each health district — “there appear to be major differences across the state,” the letter reads — to clarification on how the state planned to manage mass registration for the roughly half of all Virginians who fall into the recently expanded 1b priority group.

The Virginia Department of Health has outlined prioritized groups for the first three phases of the state’s vaccination campaign.

Hospitals have also been asking questions. In a call with the governor and other key administrators late last week, VHHA executives asked for more transparency on vaccine allocation, saying that hospitals ordered more than 50,000 vaccines the week before and only received about 22,000 — a 60 percent reduction from what they were expecting. 

In a later email, VDH spokeswoman Melissa Gordon wrote “there was no ‘reduction’ in amount expected vs received, because as all providers know, supply is extremely limited and allocations change frequently to reflect that.

“It is safe to say that all Americans — hospitals, private providers, pharmacies and local health departments — want more doses than are currently available,” she added. 

But with little public transparency on where the state is shipping vaccines — or how it’s determining its allocations to different providers — health systems aren’t the only ones with concerns. On Tuesday, Chesterfield County Public Schools Superintendent Mervin Daugherty sent an email to staff notifying them that the school system, which is planning to bring some students back for in-person instruction next month, had received far fewer doses than anticipated. 

As a result, the district had to cancel planned vaccination clinics for “Cohort 1” employees as well as elementary school staff.

“I regret that I have to share the supply chain outside of CCPS has not delivered,” Daugherty wrote. “The first shipment of shots for Chesterfield County arrived yesterday and only contained 1,000 doses. The county government is providing the school division with 750 of those doses for use with our staff.”

That 1,000-dose shipment arrived after the Chesterfield Health District put in an order for roughly 8,000 first shots (county officials anticipated receiving “at least 50 percent of that order this week,” Daugherty wrote). 

It’s not clear why the county’s allocation was so much lower than anticipated. But it’s not just affecting the school system, which has “no plans to delay the re-entry of elementary students for in-person learning” despite the shortage of vaccines, Daugherty wrote. 

Some private medical providers in Chesterfield — who ostensibly should have been vaccinated in the first phase of the state’s campaign — have also been unable to schedule shots through the health district. Many of the practices that have struggled to schedule shots are smaller providers without ties to nearby hospital systems or satellite offices in adjoining health districts, which have been more successful in administering doses.

“Richmond, Henrico and Chickahominy seem to have had greater success at distributing the vaccine, all things considered,” said Jim Beckner, the executive director of the Richmond Academy of Medicine. “Chesterfield is still struggling.”

It’s a stark contrast compared to other health districts— some of which were able to move into Phase 1b by the second week of January. That includes Fairfax, which has administered more than three times more vaccines than Chesterfield, according to state data.

Efforts in Fairfax County have been bolstered by Inova, one of the wealthiest hospital systems in Virginia. After a rocky start — one that left many primary care doctors in the dark about when they’d be eligible for a vaccine — the health system began opening appointments to unaffiliated providers in early January (Claudia Téllez, executive director of the Medical Society of Northern Virginia, said Inova notified her of the change on Jan. 4).

The health system has provided more than 38,000 vaccinations since opening its clinic in December, according to a recent staff email from CEO Dr. J. Stephen Jones. In the same message, he notified employees that the procedures for appointments has changed.

“Now that we are expanding our vaccination efforts into larger populations, we want to streamline the process for all of our team members,” Jones wrote on Friday. Starting “immediately,” all Inova employees — in addition to volunteers and contractors — could receive their vaccines without an appointment at one of the health system’s two clinics.

“Walk-ins are encouraged,” Jones wrote.

But as the health system expanded slots for its own workers, some residents in Fairfax County were notified the health district didn’t have enough vaccines available to schedule their appointments. Many of the messages went to older residents with high-risk medical conditions who were told they were eligible to register for the vaccine under Phase 1b — including a Mercury reader who forwarded a Jan. 16 email from the health district.

“We want to thank you for registering to receive a COVID-19 vaccine,” it reads. “Unfortunately, we do not have enough vaccine supply availability to schedule your appointment right now.”

Inconsistent messaging on when and how the vaccines will become available has led to widespread frustration, both for residents and local officials across the state. Chesterfield’s county administrator and board of supervisors recently released a letter “empathiz[ing] with citizens who are concerned and frustrated with the state’s vaccine rollout,” the Chesterfield Observer reported.

“We have also encouraged the state to expand the roles of local government in the vaccine campaign to further expedite the process, but to no avail,” they wrote.

State Health Commissioner Dr. Norman Oliver speaks at a press conference in August. (Ned Oliver/Virginia Mercury)

‘It is imperative to have greater coordination’

An apparent lack of local coordination has become a theme of Virginia’s vaccine rollout. In talking points drafted before a VHHA call with Northam last week, hospital executives appear surprised by VDH plans to establish mass vaccination clinics at several locations across the state (“We also understand that there have been conversations about contracting with hospitals and health systems to help support these clinics,” one point reads.) 

But with some hospitals already planning clinics of their own, executives on the call wondered if a “collaborative approach” would be more efficient to avoid duplicating efforts.  

“Moving forward, it is imperative to have greater coordination between VDH, local health districts, and hospitals/health systems to plan and execute vaccine clinics in communities across the Commonwealth,” another talking point read. “We all, to varying degrees, have resources that could support these efforts.”

Hospitals aren’t alone in asking for more collaboration. In their letter to Oliver and Avula, Hampton Roads leaders included multiple questions on how officials intended to bridge the gap between state-level plans and local operations. 

One asked if funding would be available to localities to offset costs for assisting in vaccination efforts. Another wondered if the state was anticipating any medical supply shortages — a major problem earlier in the pandemic as Virginia worked to expand access to testing.

“Are there any supply chain issues that local governments will have to work to solve for the vaccination plan to work?” local leaders asked. “Can localities assist with the procurement of these supplies?”

Staff at VCU Medical Center in Richmond receive 4,000 doses of the Pfizer COVID-19 vaccine. (VCU)

One of the most pressing requests, from hospitals and local health districts, has been for help with staffing. Mass vaccination efforts are largely dependent on having a large pool of vaccinators to help administer the shots. But the state’s post-holiday case surge has widely overwhelmed the health care workforce. 

For hospitals, the spike in admissions has forced many providers to isolate or quarantine and kept others busy with patient care. At local health departments, high case counts have dramatically expanded the need for testing and contact tracing — overwhelming already strained workforces. 

McKay, the director of policy and planning for Blue Ridge Health District, said environmental health staff would normally handle many of the logistics for vaccination clinics — including packing and transporting supplies. But since local health departments have also been tasked with administering the governor’s emergency orders, he said those same workers have been too busy with enforcement. 

National Guard members stepped in to help with logistics last week after a request from the district, according to McKay. But finding vaccinators has been another challenge. While Northam and other state officials have touted the Medical Reserve Corps — a volunteer group established to respond to public health emergencies — the reality is that many members have full-time jobs and can’t commit to fully staffing a vaccine clinic.

“It can be difficult to get volunteers to commit to the number of hours we need,” McKay said. While the district has no shortage of volunteers, onboarding is also a challenge. Even experienced providers currently have to go through at least six to 10 hours of training, including a skills test with a public health nurse. Hospitals and localities have also complained that the current prerequisites make it difficult to quickly expand the state’s vaccination workforce.

“We are seeking a temporary waiver for the non-essential requirements to more quickly facilitate the registration of additional vaccinators,” Hampton Roads leaders wrote to Avula and Oliver. “Another possibility would be for VDH to allow nurses or other qualified healthcare professionals to certify and work under our hospital systems’ emergency credentialing.”

Hospital executives have also asked the administration to ease some of those requirements through an executive order. Avula said Saturday that the state is in the process of drafting that language.

“I understand that people are frustrated, but this is a massively complex logistical challenge,” he added. “So while I understand the frustration, I think we need a lot more grace and collaboration. And I think in the coming two weeks we’re going to shift from, ‘Where are those missing doses?’ to ‘Okay, they’re getting out — how do we get more?’”

Most localities and health systems readily acknowledge the barriers presented by a chaotic federal rollout. But McKay said the lack of coordinated state messaging has also been a challenge as many local districts struggle to scale up their vaccination efforts. 

One key example is the state’s transition to Phase 1b. After what state Health Secretary Dr. Dan Carey described as “strong guidance” from the federal government, Virginia expanded eligibility to include residents 65 and older and all adults with underlying health conditions. As a result, nearly half the state’s population has been told they’ll qualify for a vaccine once their local districts enter that next phase (for some, that’s already happened, but officials say the entire state is expected to move onto 1b by the end of January).

Exhausted vaccine reserve could unravel plans for Phase 1b expansion in Virginia

The problem is that, as of now,  federal vaccine shipments aren’t expected to increase until at least March, which means Virginia’s allocation will remain at roughly 110,000 a week. And beyond the limited supply, not all health districts are getting the same level of assistance. As a result, availability will likely continue to vary widely across the state.

“Just to say we’re moving into Phase 1b doesn’t mean all those people in 1b are going to get quick access,” McKay said. “So that creates some challenges in terms of messaging. And not all districts are on the same timeline. So managing all that becomes very, very difficult.”

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Kate Masters
Kate Masters

Kate grew up in Northern Virginia before moving to the Midwest, earning her degree in journalism from the University of Missouri. She spent a year covering gun violence and public health for The Trace in Boston before joining The Frederick News-Post in Frederick County, Md. Before joining the Mercury in 2020, she covered state and county politics for the Bethesda Beat in Montgomery County, Md. She was named Virginia's outstanding young journalist for 2021 by the Virginia Press Association.