Wasting doses amid waning demand: How efforts to vaccinate in KY are changing
Anita Bertram climbed the back steps of a gray-paneled trailer on the edge of Garrison, Kentucky, opened the screen door, and knocked.
No one answered, so she knocked again. An orange cat appeared from under the porch and walked hesitantly across the grass, eyeing her and meowing. “Ms. Rowe? It’s the health department,” Bertram, director of the Lewis County Health Department said through the door.
Katie Brannon, a nurse supervisor, stood behind Bertram with a black bag on her shoulder. Inside was a single dose of the Moderna COVID-19 vaccine meant for Donna Rowe. She’d been scheduled to receive her second shot at the health department in town that morning, but the brakes were out on her car. Desperate to inject vaccines into as many people as possible in this geographically sprawling but sparsely populated Eastern Kentucky county, Bertram and Brannon didn’t hesitate when Rowe asked if they could drive the dose to her house on this early July day.
Rowe, 67, opened the door and invited the pair into her living room, which was cluttered with family photos, trinkets and other ephemera. A spread of decorative plates spanned the wall behind her couch, where she took a seat.
Brannon unzipped her bag. “Did you do OK with your shot last time?” she asked, warning that the side effects following the second one may be worse. “Just take you some Tylenol or Motrin if you need to, OK? A lot of people get pretty sore after that second one.”
Rowe has asthma and diabetes, and because of that, “my doctor told me I needed to” get the vaccine. “Plus, I want to be protected,” she said as Brannon readied the needle.
Rowe’s choice to get a vaccine makes her an anomaly in Lewis County, where fewer than 24% of residents are at least partially vaccinated against COVID-19 — one of the lowest rates not only in Eastern Kentucky, but the state.
“With our vaccination rate not being very high, I feel like we’re always just one funeral or one wedding away from another big outbreak,” Brannon said later in the car. Bertram wants people in her community to know, “If you can’t come to us, call us and we will come to you.”
Their shared worry is a continued reality for thousands of Kentuckians who live in these counties where more than 60% and in some cases 70% of their neighbors, friends and co-workers remain unprotected against the coronavirus. Though more than half of Kentucky’s population is at least partially vaccinated, those rates are concentrated in cities. Of the state’s 120 counties, 69 have individual vaccination rates under 40%, and in a dozen, 30% or fewer people are vaccinated, according to the Centers for Disease Control and Prevention. The doses are there, people just aren’t claiming them. And public health personnel are at a loss for how to reach the holdouts.
As vaccine demand in many rural parts of Kentucky has all but dried up, breaking the seal on a vial of Moderna vaccines and driving one dose to Rowe’s home is also representative of a new strategy some health departments are adopting out of necessity — wasting usable doses, even if it means getting just one shot into someone’s arm.
It’s a step that was inconceivable a few months ago, when vaccines were far less plentiful and demand was surging. And it was a point of pride for Gov. Andy Beshear, who boasted numerous times throughout the spring that Kentucky hadn’t wasted a single dose. But on May 18, in a memo to vaccine providers, the CDC acknowledged the changing landscape.
“While we want to continue to follow best practices to use every dose possible, we do not want that to be at the expense of missing an opportunity to vaccinate every eligible person when they are ready to get vaccinated,” the CDC said. “As as we continue to create more opportunities to vaccinate more people, it may increase the likelihood of leaving unused doses in a vial.”
Now, as new cases are rising again in the state after months of decline, fueled in part by spread of the more contagious delta variant, and with an eye toward late summer when in-person school starts, Bertram and other public health personnel across eight Eastern Kentucky counties say they don’t have a choice. As they brace for potential surges — the level of community spread is back in the red in Lewis County, where the number of active cases has more than quadrupled in the last week — wasting doses to get even a few people vaccinated is the new normal.
“If somebody comes in and wants to be vaccinated with Moderna, and it’s 5-o-clock, then we’re going to vaccinate them and waste nine doses,” Bertram said. “We’re at that point. I would much rather protect one person and waste if I have to.”
‘The urgency is just gone’
Each vial of the Moderna vaccine shipped to health care providers around the country usually contain 10 doses, while a Pfizer-BioNTech vial contains six, and the single-dose Johnson & Johnson vaccine is packaged in vials of five doses. Though the storage and thawing of all three varies, once a seal is broken on a vial, all doses need to be administered within hours, or they expire.
Earlier this year, when limited supply could not keep up with the deluge of demand in Kentucky, health departments like Bertram’s physically couldn’t dole them out fast enough. In February and March, when health care personnel, teachers and people over the age of 70 were eligible, the Lewis County Health Department was shipped 100 doses a week.
If someone didn’t show up to an appointment, to avoid wasting even a single shot, it was common for Bertram’s staff to hustle to the Dollar General store next door and ask over the intercom whether anyone wanted to pause their shopping to get vaccinated.
Demand was so high, “people would get mad at us for not having them,” Bertram said. “And now the pendulum has just gone the other way.”
Other health departments have begun regularly discarding leftover doses out of necessity, too.
At the Gateway District Health Department, spanning Bath, Elliott, Menifee, Morgan and Rowan counties, public health staff recently set up an off-site vaccination clinic at the fire department in Sharpsburg in Bath County, where the vaccination rate is higher than Lewis County’s, at nearly 41%.
Director Greg Brewer advertised the clinic on the radio and put up signs directing people . But only two people showed. The other doses in the vial had to be thrown away.
“We tried. It just didn’t go good,” Brewer said of the turnout. Months ago, “people were begging. Now we’re begging. The urgency is just gone.”
‘What else can I do?’
Fifty miles east of Garrison, at the Germantown Volunteer Fire Department, Victor McKay straightened a clipboard on a registration desk next to a sign that announced, “Today we are offering the J&J vaccine.”
The room was empty and so was the parking lot. No one had signed up, yet, but McKay, director of the Buffalo Trace District Health Department, and his clinic nurse Linda Stahl were hopeful. At their two mobile clinics the week before in Orangeburg and Lewisburg, only three people had come asking for doses. McKay had promised to buy his staff lunch if six showed up today.
A truck turned onto an adjacent street that connected to the parking lot of the clinic, appearing at first like it might turn in. It didn’t.
“See, that’s a tease,” McKay said, deflated.
Germantown straddles the Bracken County and Mason County line, where vaccination rates are 35% and 41%, respectively. His district also includes Robertson County, lagging with 23.5% of people vaccinated.
On this mid-July morning, he’d enlisted his postmaster friend to advertise the clinic to all post office visitors. “I say don’t even give them their mail until they come over, until they bring you back one of these,” he joked, holding up a vaccination card.
McKay takes it personally when his clinics aren’t successful, or when his staff are forced to discard usable vaccine doses. Like in Lewis County, it was easier to find willing recipients for straggler doses in the spring. But as demand has waned, the constant scramble to avoid discarding doses became untenable and, eventually, impossible.
“It was like that on a constant basis,” McKay said. Assurance from the CDC that wasting doses under these circumstances is inevitable helps take the pressure off, but “the failure factor still comes into play,” he admitted. “It’s a lifesaving vaccine. Nobody wants to throw it away.”
Like Bertram, McKay and his staff have tried just about everything to push vaccines, short of going door to door. McKay drives his department’s mobile vaccine unit to different community centers each week, hangs fliers, advertises on the radio and in the local papers, texts people he knows who aren’t yet vaccinated and asks others who are to do the same. This weekend he’ll post up at Blue Licks Battlefield State Resort Park for a few hours with plans to meander through the campground Saturday morning to ask if anyone wants a shot with their morning coffee.
Stahl brought six vials — 30 doses — of Johnson & Johnson to this clinic. Once the seal is broken on one, they have six hours to administer all five doses before they expire. Like in Lewis County, the Buffalo District holds a vaccine clinic each Friday at their brick and mortar location. At the last one, a few people trickled in wanting a Johnson & Johnson vaccine, but not enough to claim all five doses in a vial.
“We had to waste two or three doses, but at least we got two or three people vaccinated,” Stahl said.
McKay’s phone rang. It was Bracken County Health Department Director Tony Cox. The two talked about McKay’s “last hurrah” plan to place fact sheets in every mailbox in his district offering, like Bertram, to drive a vaccine to people’s homes if they wanted it.
“If it’s a lack of means to get to it, then I want to be able to say that we made every effort to get it to them,” he said.
A half-hour elapsed. Then an hour. McKay made a call to one of his staffers. He knew two people who owned a popular bar five miles away that weren’t vaccinated.
“Tell them if they come get their shots, the next round is on me,” he said into the phone.
A few minutes later, McKay got a text. “They said no,” he announced to Stahl.
The last few minutes of the clinic ticked by. Stahl rose from her seat next to a table of ready syringes to stare out the window. They would soon transport their vaccine supply to another community fire department in neighboring Fernleaf for two hours. No one would show up there, either.
“You finally just go, ‘What else can I do?’ I just have to keep reminding myself that all we can do is make the vaccine available,” McKay said, stacking his registration clipboards. “Maybe we’ve just reached everybody that’s going to get it. There is that possibility. But I don’t want to settle for that answer.”
