Shots are slow to reach arms as Trump administration leaves final steps of mass vaccination to beleaguered states

In suburban Milwaukee, clinicians recently discarded 500 doses of coronavirus vaccine after vials were left unrefrigerated. In southeastern Arizona, a rural clinic has enough shots but too few employees lining up to take them. And on the coast of Maine, physicians have been left in the dark about when they will get vaccinated.

The largest immunization campaign in U.S. history is off to a slow start, dimming hopes, at the end of a dismal year, of an imminent return to normal.

In some places, the vaccination campaign - among the most complex logistical efforts undertaken in peacetime - has been marked by chaos and confusion. Many medical workers who believe they should have priority access are finding that inoculation remains elusive. And most states moved into the third week of immunization not yet beginning to get shots to long-term care facilities, which have been epicenters of infection.

The result is the delayed administration of vaccines during the deadliest month of the pandemic so far. As of Wednesday, 12.4 million doses had been distributed nationally, while 2.6 million had been administered, according to the Centers for Disease Control and Prevention.

Those figures, which Trump administration officials insist lag behind the actual number of vaccinations, mean just 1 in 125 Americans have received an initial shot of protection. In Israel, which began its immunization campaign nearly a week after vaccinations got underway in the United States, about 1 in 20 residents have received a shot.

Nancy Messonnier, director of the CDC's National Center for Immunization and Respiratory Diseases, said the pace would accelerate starting next week but acknowledged, "We've always expected and prepared for bumps in the road."

"We need to remember that these are new vaccines on new platforms with slightly complex requirements for storage, handling and administration," she said during a Wednesday briefing.

The reasons for the slow start in the United States include a chronic lack of public health funding and the absence of unified communication about the vaccines and their availability. Each state is deciding for itself how to prioritize residents, how to alert people of their place in line, how to sign them up, how to police eligibility, how to promote uptake, how to configure vaccination sites and how to muster the workforce to get it all done.

Many decisions are being left to hollowed-out county and municipal health departments and hospital systems confronting a surge of people with covid-19, the illness caused by the virus.

"The most ambitious vaccination effort in modern history involves delivering millions of doses to millions of people in a timely fashion," said Howard Koh, a professor at Harvard University's T.H. Chan School of Public Health and an assistant health secretary in the Obama administration. "It requires a one-government approach more than ever before, especially when that government is in the midst of a transition."

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President Donald Trump's approach - furnishing states with vaccines but leaving them largely alone to conduct vaccination - is at odds with how President-elect Joe Biden is vowing to govern. The Trump administration, which initially promised several hundred million vaccine doses in 2020, is on the brink of missing even its revised target of 20 million doses distributed by year's end, with enough in reserve for booster shots several weeks later.

Even more striking is that a small fraction of those doses have made their way into people's arms. Without a significant speedup, vaccinating enough people in the United States to achieve herd immunity will take years, not months.

The logistics will grow more complicated as states next week begin handling booster shots, which must be administered 21 days after the initial dose of the Pfizer-BioNTech vaccine. The two doses are spaced 28 days apart for Moderna's vaccine, the second to gain regulatory clearance in the United States. Additional vaccines could become available in coming weeks, including a single-dose regimen developed by Johnson & Johnson.

"I'm confident this will get resolved for health-care workers and we'll all get vaccinated soon, but what does it say about the obstacles for the general public and about their confidence in the process?" said Kavita Patel, a physician who served in the Obama White House and is now a nonresident fellow at the Brookings Institution. "If things continue like this, people in higher-income communities with more mobility and access to capital will get vaccinated and others will fall through the cracks."

The feat of making and shipping the vaccines, backed by a budget of $18 billion in public money, is giving way to the challenges of using the precious resource. Biden, who will become responsible for the effort in about three weeks, warned Tuesday that the Trump administration was "falling far behind" in immunizing the public, a critical step in allowing Americans to travel and return to work.

Greater federal oversight promised by Biden will help identify gaps "so that some jurisdictions are not doing better than others," said Julie Morita, a member of the president-elect's coronavirus advisory board and a former public health commissioner in Chicago. Resources could be rushed to certain areas, she said, to avert the inequalities that marked the rollout of testing. Many states, she said, will need support building out the workforce required to administer thousands of shots every day.

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For now, states are moving in different directions, exposing fissures in a national effort to curtail the pandemic.

A case in point is use of the National Guard. Clay Marsh, coordinator of West Virginia's coronavirus task force, said the state is treating vaccine distribution "like a military operation." The head of its National Guard is leading the effort. But in Montana, the fourth-largest state by area, the National Guard was still "on standby," said Matthew Quinn, the state Guard's adjutant general.

"I have combat medics who could do vaccination or support clinics," Quinn said, anticipating that Montana and other states may call on reinforcements as immunization broadens beyond medical workers and nursing home residents, who are among those in the first priority group.

Soon, he said, vaccination sites could resemble drive-through testing centers, especially now that states can count on $8 billion in federal funding for vaccine distribution, part of the stimulus package signed Sunday by Trump.

Ashish Jha, dean of Brown University's School of Public Health, said those are priorities the Trump administration should have embraced - and made the subject of urgent consultation with states - starting Nov. 9, at least. That was the day Pfizer said the vaccine it was developing with the German company BioNTech was more than 90 percent effective.

The notion that states can rely on systems they use to deliver the annual flu vaccine, or "efficiently stand up new infrastructure," Jha said, "is a fantasy." The $350 million already provided by the Department of Health and Human Services to health-care systems for pandemic response was insufficient, he said. And the additional $8 billion allocated by Congress for vaccine distribution arrives too late for states to have figured the resources into their initial planning, he said.

"This is not how you handle the biggest health, economic, political and social crisis the country has faced in decades," Jha said. "There's a lack of seriousness."

Officials leading Operation Warp Speed, the Trump administration's accelerator for vaccines and therapeutics, said rollout has been slower than they were hoping but still estimated that members of the general public would gain access by April.

Gustave Perna, the four-star Army general acting as the initiative's chief operating officer, said the holidays and three snowstorms posed barriers to the rapid administration of doses. At a Wednesday briefing, he stressed that states are in charge of the "final administration" of doses, which he called an "incredible task," but maintained that the federal government had overseen extensive coordination, including making regional planning teams available "24 hours a day, seven days a week," to state and local governments.

He did not point to significant issues with waste or shipment errors. There have been few reports of incidents similar to the one over the weekend in Grafton, Wis., in which clinicians had to throw away about 500 doses of the Moderna vaccine because vials had been left out overnight.

But referring to shots in arms, Moncef Slaoui, Operation Warp Speed's scientific adviser, said, "We agree that number is lower than what we hoped for."

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Cracks are emerging, and some state officials are making their dissatisfaction known.

In Tennessee, a report prepared this week by state emergency managers and reviewed by The Washington Post warned of looming shortages of dry ice needed to prevent vaccine from spoiling. Discussions were underway, the report said, about when to "dip into stockpile."

In Ohio, Gov. Mike DeWine, a Republican, said he is asking hospitals to "do everything in their power" to get vaccine to recipients within a day of receiving the supplies. "There's a moral imperative to get this out just as quickly as we can," he told reporters on Wednesday, adding, "I'm not satisfied."

The top public health official in Texas was concerned enough about the pace of vaccinations that he issued a directive on Christmas Eve telling "all entities that have been allotted vaccine to administer their entire allotment with all deliberate speed."

"The time to vaccinate willing individuals is now," Health Commissioner John Hellerstedt wrote.

His directive suggested part of the slowdown was the result of fears of supply drying up and the perceived need to finish vaccinating in the initial phase - medical workers and residents and staffers at long-term care facilities - before moving to later priority groups.

Rachel Levine, secretary of health in Pennsylvania and president of the Association of State and Territorial Health Officials, said that "logistically, this is taking more time, at least in the first two weeks, than the federal government anticipated."

In interviews, state officials pointed to a range of reasons for the delay, including the Christmas holiday and initial uncertainty about the size of vaccine shipments. Just 14 states began vaccinations in long-term care facilities last week, through a program managed by CVS and Walgreens, with 13 more expected to start this week, Perna said. Consumer advocates and health officials say the federal government could have expedited the process by providing clearer directions about the need for consent among elderly and infirm residents.

Many states have set aside shots for the chain pharmacies to use in long-term care facilities, which partially explains why administered doses lag behind distributed doses, said Claire Hannan, executive director of the Association of Immunization Managers. The numbers will grow considerably, Hannan predicted, "when we start seeing CVS and Walgreens getting things done in long-term care facilities."

But hesitancy among nursing home staffers looms as a significant hurdle. Lori Porter, who leads the National Association of Health Care Assistants, said polling she has reviewed suggests a significant majority of people working in stricken facilities "are a hard no" on taking the vaccine. "Often, people have to see something before they can believe something, especially in this political climate," she said, predicting at least moderate improvement as immunization becomes a reality across the country.

With hospitals, some are running out of shots while others are keeping doses on shelves, health-care leaders said. Certain facilities are being meticulous about vaccinating staffers in waves to make sure that if workers experience side effects, that will not interfere with hospital work.

Still, the complaint aired most frequently "is that the cupboard is bare," said Kenneth Raske, president and chief executive of the Greater New York Hospital Association.

Elsewhere, the rush to distribute the shots is creating unintended consequences, including crowding that risks exacerbating virus transmission. Lee County in southwestern Florida issued a notice Sunday inviting all medical workers and adults 65 and older to line up at first-come, first-serve vaccination sites. The sites reached capacity before opening Tuesday, and state health officials stationed in the county were not available for interviews about the initiative's progress, because of the number of staffers deployed to the locations.

Sign-up programs differ widely across the country: Some hospital systems are going alphabetically among eligible cohorts. Others devised more complex algorithms.

The District of Columbia has unveiled a portal that members of the public, not just medical workers and those in early priority groups, can use to complete a vaccine questionnaire. In Maryland, the state medical society is advising community doctors that health departments "have not yet announced a schedule or details."

In a rural county in Arizona, some shots made available to medical workers are going unused. Gail Guerrero-Tucker, a family physician at a 45-person clinic in Safford, said only 20 wanted the vaccine. "No one's lining up for it," she said.

At the opposite end of the country, on the coast of Maine, a family-medicine physician who runs her own practice in the poorest county in the state has been unable to get an answer about when she can get vaccinated. "We are not trying to jump the line, just trying to ensure that we are IN the line," the physician, Cathleen London, wrote recently to officials at the Maine Center for Disease Control and Prevention.

The response she received asked her to enroll as a vaccine provider, which she had already done. "Afraid I can't give you a whole lot of detail as yet," she was told, according to correspondence reviewed by The Post.

Nirav Shah, director of the Maine CDC, said at a Wednesday briefing that it was always the state's plan to start with hospital-based providers and that officials were still working through "when and how" to reach other medical workers.

“We’re about to have our biggest surge yet,” London said. “We’re in trouble. Why aren’t there more details?”