Hospitals have gotten the lion’s share of Virginia’s early vaccine shipments — raising concerns over equity

In the early weeks of Virginia’s COVID-19 vaccine rollout, hospital systems in five local health districts requested, and received, tens of thousands of doses — a disproportionately larger share than pharmacies, community health clinics and even the local health departments charged with overseeing the state’s immunization plan.

In Chesterfield, for example, HCA Virginia requested 27,775 first doses from Dec. 14 to Dec. 20 and ultimately received 18,275 — more than enough to vaccinate what Jeff Caldwell, the system’s vice president of communications, described as more than 17,000 total employees across the state. VCU Health in Richmond requested and received 20,050 first doses within the first three weeks of the state’s rollout — far more than its roughly 13,000 employees (spokeswoman Alex Nowak said the health system also has more than 10,000 “affiliated team members,” which include residents, medical students and food service workers, but not every direct or affiliated employee is involved in patient care.)

The Mercury obtained detailed distribution data for the Richmond, Henrico, Chesterfield, Fairfax and Central Shenandoah health districts from a reader, who noticed that the Virginia Department of Health’s public vaccine dashboard initially allowed the public to download spreadsheets showing how many doses were delivered to individual facilities.

After she emailed VDH with questions about the data, the department disabled the feature. Dr. Danny Avula, the state’s vaccine coordinator, said there are plans to re-release the same information on the dashboard this week. 

But those preliminary spreadsheets, which cover distribution from Dec. 13 to Jan. 24, show that hospitals in several large health districts received the lion’s share of Virginia’s early vaccine allotments even after concerns emerged over how they were distributing them — including that some doses were going to stay-at-home workers, not just frontline doctors or nurses. In the first six weeks of the state’s rollout, 11 hospitals in those five districts received a total of 236,000 doses. Local health departments received 108,300 — less than half of the total distribution to hospitals. 

Pharmacies, private medical practices and community health clinics accounted for fewer than 19,000 of the doses distributed in the first month and a half of Virginia’s vaccination campaign. It’s an issue that’s continued to affect the equitable distribution of the vaccine as hundreds of thousands of Virginians wonder when they’ll be eligible. 

Understanding how early shipments to health systems dictated, in many ways, who could get the vaccine requires going back to the beginning of the state’s vaccine rollout. It was always expected, and intended, that hospitals would receive the earliest shipments — both to route the life-saving doses to their frontline health workers and to store the vials, some of which required ultra-cold freezers that many hospitals were already equipped with.

But there were also guidelines that hospitals were expected to follow. The state’s own guidance for Phase 1a, the first stage of the rollout, reserved vaccines for frontline health workers engaged in patient care. Julian Walker, the vice president of communications for the Virginia Hospital and Healthcare Association, said there was also the explicit understanding that hospitals would share their shipments — by redistributing doses to other facilities or by assisting their local health departments in vaccinating medical providers who didn’t work for the health systems.

But two things happened in the weeks after shipments began flowing to the hospitals. One was that many frontline medical employees refused the vaccine. According to Avula, anywhere from 40 to 50 percent of hospital workers declined a first dose during the initial rounds of shipments from mid-December to early January. The group Immunize Virginia, a nonprofit coalition dedicated to improving vaccine coverage, is working on a more detailed data analysis, but hadn’t made it publicly available as of Monday.

In an interview last week, Avula said uptake has improved as early holdouts — encouraged by colleagues who safely received the vaccine — have signed up for doses. But in the first few weeks, it left many health systems with an unexpected number of unused shots.

“They all requested vaccine based on 100 percent of their staffing, but only 50 to 60 percent of their staff actually took the vaccine in the first go-around,” Avula said, adding later that that was when hospitals “probably opened up who they were offering the vaccine to in their systems.”

That led to a second development — shots that weren’t always administered how the state intended. By late December, many large health systems, including VCU Health and Inova in Northern Virginia, had opened vaccine appointments to work-from-home employees who hadn’t entered a medical facility since March. During the same time period, many unaffiliated medical providers were struggling to find appointments through their local health departments.

In some cases, hospitals didn’t immediately start offering assistance. Inova, for example, initially directed independent providers to “contact their local health department to coordinate vaccine distribution,” according to a Dec. 22 email from spokeswoman Tracy Connell. 

It wasn’t until Jan. 4 — after the Medical Society of Northern Virginia sent a concerned letter to state Health Secretary Dr. Daniel Carey — that the health system announced it would open vaccine appointments to community providers. Even after Inova and VCU Health began vaccinating work-from-home employees, both systems received more than 3,000 additional first doses from the state (Inova, in fact, received more than 35,000 first doses from early January until the state changed its distribution strategy late in the month).

In a statement on Monday, Connell wrote that the health system expanded vaccination appointments less than three weeks after “optimizing operations and expanding scale at our vaccine clinic, which has delivered more than 128,000 doses to date.”

“Subsequently, Inova proactively engaged numerous provider organizations and large independent practices and encouraged them to take advantage of Inova’s vaccine clinic,” she said.

Second-dose stockpiles

In interviews to discuss the initial distribution data, Avula cautioned there were a few caveats to the spreadsheets. One is that large shipments to hospital systems might have been partially redistributed to other providers — something the state itself has struggled to track. 

Because vaccines are supplied through the federal government, Virginia manages its inventory with VTrckS, a system provided and administered by the U.S. Centers for Disease Control and Prevention. Avula said the state receives a certain allotment of vaccine from the federal government every week, and uses VTrckS to pull down and directly fulfill orders. But the platform doesn’t always make it clear when health systems transfer doses to other provider facilities. 

“Sometimes it’s super obvious, but a lot of times, it’s not,” Avula said. Much of the state’s work to improve its ranking in the rate of vaccines administered — once the lowest in the country, but now 20th among all 50 states and Washington, D.C., according to Feb. 14 data from the CDC — was manually combing through the distribution data to track how many doses were redistributed to which locations. 

Avula said that granular data is set to be re-released once it’s updated to reflect redistribution. He also emphasized that many health systems were instrumental in delivering vaccines to their communities. 

Valley Health, for example, worked closely with the Lord Fairfax Health District to set up mass vaccination sites in Shenandoah University’s auditorium. Caldwell, the spokesman for HCA Virginia, said the health system has vaccinated 4,700 unaffiliated providers and first responders, and “reallocated nearly 4,000 doses to other health systems and health departments.”  

But even as many health systems set aside some of their vaccines for the surrounding community, it became clear to many state officials that they were holding onto large numbers of surplus doses. In late January, the state quietly changed its allocation strategy to route all doses through local health districts based on their share of the state’s population — essentially removing the ability for hospitals to request doses directly from VDH. 

That same week, multiple officials, including Avula and Clark Mercer, the chief of staff for Gov. Ralph Northam, said that the large gap between the number of doses distributed across Virginia and the number that had actually been administered was largely due to hospitals reserving second doses — even if they weren’t due to give them out for weeks.

According to Avula, that happened for multiple reasons. Vaccines distributed through VTrckS aren’t explicitly labeled as second doses, which “did create some challenges in managing inventory at the site,” he said (though in most cases, second doses were delivered on the same week, and in the same quantity, as first doses, making it fairly clear what they were intended for). 

Federal mismanagement also contributed to widespread confusion over how many doses states could actually expect to receive. In mid-January, Northam announced that Virginia would expand its 1b eligibility after then-Health and Human Services Secretary Alex Azar announced the Trump administration would release a stockpile of vaccines. 

The next day, The Washington Post reported that the promised stockpile didn’t actually exist. Virginia’s allocation has gone up slightly over the last few weeks — from around 105,000 weekly doses to around 130,000 as of last week — but local health departments still receive only a tiny fraction of the shots needed to immunize their communities. 

The Richmond-Henrico Health District, for example, receives 6,300 doses a week for a total population of about 560,000.

“So, that’s barely above one percent of the population,” said Nurse Manager Amy Popovich. “It’s very small.”

Those strict limits on allocation are part of the reason early shipments to hospitals have been frustrating to many across the state. Health systems began receiving doses before the state learned that its weekly allotment would remain sharply limited, and before many providers were fully set up as vaccinators. As a result, Avula said that most health systems received the full number of doses they requested. 

It wasn’t until the first week of January — about when Avula was appointed to head the state’s vaccine coordination effort — that most hospitals saw a reduction in their shipments.

And while many have redistributed some of their doses, it’s often been to primary care practices within the umbrella of the larger health system. It’s why the Virginia Hospital and Healthcare Association reports that hospitals have administered just over 71,000 more doses than the state’s dashboard currently reflects. Walker said the association’s accounting includes vaccines administered by hospitals and by primary care systems within the health system.

‘We just don’t have the authority or the infrastructure’

The consequences of Virginia’s early distribution strategy are still reverberating across health districts. The Virginian-Pilot reported Saturday that primary care doctors outside large health systems are growing increasingly frustrated by their inability to access vaccines for their most vulnerable patients. And across the state, some Virginians have been able to access vaccines as health system patients while others have struggled to figure out when they might be eligible for a shot through their local health departments.

Sentara, VCU Health, Bon Secours and Riverside are among multiple health systems that have defended their decision to offer COVID-19 vaccines directly to their patients. Avula said that kind of prioritization stands in clear opposition to the state’s goal of equitable distribution, and it’s led to considerable disappointment for many Virginians who are desperate to schedule appointments for themselves or for medically vulnerable relatives.

Betty Smith, a resident of the Three Rivers Health District, which covers 10 counties in the Northern Neck and Middle Peninsula areas, said she’s been trying for weeks to access shots for her parents — who are Black and over the age of 75 with underlying medical conditions. But while she’s struggled to get more information from her local health department, the district has directed patients with Riverside and Bon Secours to sign up for appointments through the health system.

“Well, my parents aren’t patients with Bon Secours or Riverside,” said Smith, whose parents live in rural King and Queen County. “The closest Bon Secours is in Mechanicsville, so more than 35 minutes away. The closest Riverside is probably an hour away. So I’ve really been at a loss on where they would even go for an appointment.”

Health officials have acknowledged that when hospitals prioritize their own patients, it deepens existing inequities and undermines the state’s own goals for fair distribution. But there’s also been little overt effort to stop it. In late January, Avula asked six health systems to convert some of their second-dose stockpiles into first doses and redistribute it to local health departments. As a result, some districts were able to vaccinate thousands more in their communities — including Richmond-Henrico, which received 7,000 doses from VCU.

But Smith pointed out that the one-time transfer largely benefited residents in communities close to those health systems. And while Avula said the state has urged them to think of the vaccine as what it is — a publicly funded resource — health systems were never ordered to stop prioritizing their own patients for the vaccine. Most have stopped scheduling patient appointments, but only because the state’s allotment is tightly limited and they’ve largely used the majority of their early doses.

“We just don’t have the authority or the infrastructure to provide that level of management and accountability,” Avula said. “And I’d say that’s one of the challenges of where we are right now. We have so many different providers who are receiving vaccine, but not the staff to be able to support them and check in with them and make sure they’re moving inventory.”