California lags far behind the rest of U.S. in COVID vaccinations. What went wrong

The Sacramento Native American Health Center had vaccinated most of its staff against COVID-19 and was ready to move on to hundreds of sick and elderly clients.

But last week Sacramento County health officials vetoed the idea. The county had yet to finish giving shots to other healthcare workers and residents of long-term care facilities, who got top priority under California’s system for vaccinations. The Native American clinic’s clients would have to wait.

“That’s all the information I got. I didn’t get any specific dates,” said Wendy Calderon, the center’s director of health services.

California overhauled its coronavirus vaccine distribution plan Wednesday, a move designed to speed up a program that had been sputtering badly and trailed much of the rest of the country.

So far the state has vaccinated just 2,468 people per 100,000, a rate that falls well below the national average of about 3,300, according to federal data.

What went wrong? The tiered system for prioritizing vaccinations was arguably too complicated — and too cautious — for its own good. A software platform to help manage the vaccine program, supplied to the state by a nonprofit organization based in Maryland, has been criticized for being clunky. Confusion erupted about the opening of mass vaccination sites at places such as Sacramento’s Cal Expo.

Fewer doses of the vaccine arrived in California than anticipated. And, as much as anything, a health-care system that was already stretched by a fresh wave of coronavirus infections has been struggling with the added task of administering vaccinations.

Four weeks after vaccine distribution began, California has administered just 891,000 of its first 3.4 million shots, or barely 26%, according to data compiled by Bloomberg news.

The average across the country is 36%. Only Alabama, Georgia and Virginia have performed worse by percentage than California at exhausting their allotments.

That woeful performance could prove costly to California in the near future: The federal government is preparing to roll out fresh supplies under an allocation formula that it says will be based in part on how quickly the states have used up the supplies they’ve received so far.

On Wednesday California announced a restructuring of its distribution system, opening up vaccines to every Californian who is 65 or older. Gov. Gavin Newsom, who has acknowledged that the vaccine distribution hasn’t gone as smoothly as expected, said the new rules will make 6.6 million Californians, who face higher mortality risks, now eligible for the vaccine.

The announcement wasn’t exactly a surprise; the U.S. Department of Health and Human Services told states a day earlier to begin making vaccines available to those 65 and older.

Yet in California, the Newsom administration’s decision sparked fears that demand would outstrip supply. Advocates for low-income groups worried that disadvantaged Californians would get left behind in the stampede for vaccinations. Health officials in Los Angeles County, one of the nationwide epicenters of the pandemic, warned that they don’t have nearly enough vaccines to begin inoculating seniors.

And a public health expert said he’s afraid so many people will get their initial vaccination that there won’t be enough vaccine available for the all-important second doses — which must be administered within three to four weeks of the first dose, depending on the brand.

“Righting the ship by pushing out everything we’ve got is an unforced error,” said Andrew Noymer, an infectious disease and public health expert at UC Irvine. “The second dose won’t arrive on time.”

An ‘overly cautious’ vaccine program

California’s governor got right to the point.

In late December, shortly after the initial shipments of vaccine arrived, Newsom issued a stern warning to doctors thinking of letting friends or family members cut in line and get a vaccine before they were supposed to.

“I just want to make this crystal clear: If you skip the line or you intend to skip the line, you will be sanctioned, you will lose your license,” Newsom said during a press conference. “You will not only lose your license, we will be very aggressive in terms of highlighting the reputational impacts as well.”

Newsom’s warning set the tone: California was going to be careful about distributing the Pfizer and Moderna vaccines.

In line with recommendations from the federal Centers for Disease Control and Prevention, the state laid out a complicated tiered priority system that emphasized vaccinating Californians according to “risk, exposure and equity,” said Dr. Mark Ghaly, secretary of the state’s Health and Human Services Agency.

The state drew up an elaborate game plan for dissemination, with phases and tiers, delineating exactly what order people get the vaccine. The goal was to get to the highest-risk people first, and to assure equity, so that less advantaged people, such as essential farm workers and service industry staff, don’t get left behind.

In the top tier: healthcare workers and residents of skilled-nursing facilities, assisted-living facilities and other venues that house “medically vulnerable individuals.”

But instead of a clear pecking order, the result was confusion and a sluggish rollout. Anthony Wright, director of the California consumer advocacy group Health Access, said the “complexity of the messaging” about the tiers made medical providers uncertain and “overly cautious” about dispensing vaccines.

State officials acknowledged the process was probably too methodical. Ghaly told reporters Tuesday that the state’s approach “has led to some delays in getting vaccine out into our communities.”

After reports came out of some dosage waste, the Newsom administration tried to move the lines last week, telling county health officials they could consider giving doses to lower priority people if it meant avoiding wasting one of the doses from an open vial.

The landscape began changing dramatically Tuesday. The Trump administration, under fire for the slow distribution of the vaccines at the nationwide level, told the states to begin vaccinating seniors 65 and older.

The secretary of the U.S. Department of Health and Human Services, in announcing the new plan, criticized states for not vaccinating seniors sooner.

“Some states’ heavy-handed micromanagement of this process has stood in the way of vaccines’ reaching a broader swath of the vulnerable population more quickly,” said Alex Azar, secretary of the federal Department of Health and Human Services. “There was never a reason that states needed to complete vaccinating all healthcare providers before opening vaccinations to older Americans and other vulnerable populations.”

Azar didn’t single out California, but state Sen. Richard Pan, D-Sacramento, said the state’s fixation on not vaccinating people out of the tiered priority order likely contributed to California’s slow distribution.

“That slows things down when you have all these tiers and subgroups,” Pan said. “We want to be equitable, at the same time the more layers we put there … that becomes really challenging especially as you move to start vaccinating the community. ... We’ve really got to step back and say, ‘How do we make it as simple as possible?’ ”

In Sacramento, patients told to wait

It’s true that California has done a poor job of using up the vaccines it’s already been given, compared to other states. Yet it’s also true that some providers in California are dealing with scarcities. UC Davis Medical Center, among others, has said it could be vaccinating more people if it had the shots available.

And on Thursday, Sacramento County warned that most residents 65 and older — a group that numbers more than 200,000 — won’t be getting shots right away.

“We request patience as we work to navigate the rapidly changing landscape of vaccination best practices and availability,” said county Public Health Officer Dr. Olivia Kasirye in a prepared statement.

It’s a warning that probably sounds familiar to officials at the Sacramento Native American health Center.

The center had already received dozens of doses from the federal government, enough to get most of its staff vaccinated, said Calderon, the director of health services.

Calderon said the health clinic wanted to start vaccinating at least 1,000 or so of its clients right away — elderly and chronically ill patients who were next in line under the priority system California had originally imposed.

County health officials offered vaccines to the center, but said they couldn’t be used for those high-priority individuals. The reason was the county hadn’t wrapped up vaccinating the first tier of recipients: healthcare workers and nursing-home residents.

The state’s decision to open up vaccines to everyone 65 and older is, in part, designed to fix that. But while the red tape has been cleared, the clinic now has to wait for supplies to arrive.

The center is opening a drive-thru vaccine clinic to provide shots and is excited about the prospect of inoculating a broad population, said spokeswoman Jeanine Gaines, “once we have it.”

Meanwhile, some advocates for low-income Californians and disadvantaged communities fret that the state’s new strategy on vaccine distribution could actually leave those groups in the dust.

“We know that if it’s first come first served, the folks who have resources, folks who have connections are far more likely to get vaccinated than folks who don’t,” said Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials.

“We have to be very careful,” Plescia said. “We’ve already seen a huge disparity in the burden of COVID in low income populations and populations of color. And if we don’t really pay attention, we’ll see the exact same thing repeated as far as the availability of vaccination.”

Did software slow vaccine distribution?

California is one of 20 states relying on a software platform developed by a Maryland nonprofit to help manage the vaccine program. Some in the healthcare community say the software, called PrepMod, has contributed to the slowdown in vaccinations.

Barbara Ferrer, public health director in Los Angeles County, told the Los Angeles Times last week that the system has problems. A spokeswoman for the California Association of Health Facilities, which represents skilled-nursing facilities, said her members have been complaining about PrepMod, too.

“There’s been talk about changing to different software. ... The state is clearly aware of this issue,” said Deborah Pacyna, the association’s public affairs director.

The California Department of Public Health told the Times that it has been “working with the vendor to work on finding solutions.”

Pacyna said the problems with PrepMod have been particularly evident in L.A. County, home to more than 300 skilled-nursing facilities. Every other county has partnered with pharmacy chains CVS and Walgreens to handle vaccinations at the facilities; the pharmacies handle the paperwork, deliver the vaccines to the facilities and administer the shots, she said.

But she said L.A. County isn’t partnering with the pharmacies because it wanted to avoid using the Pfizer vaccine, which requires special refrigeration. As a result, facilities in L.A. County have to fill out the vaccination paperwork themselves, a process that requires registering with two state-run databases before shots are administered. The PrepMod system, the third step in the process, documents that someone’s been vaccinated and uploads that information to the state.

PrepMod “is clunky,” Pacyna said. “It’s not very user friendly.”

The executive behind PrepMod said the software is getting tarnished unfairly. Tiffany Tate, president of the Maryland Partnership for Prevention Inc., the nonprofit responsible for PrepMod, said state and L.A. County officials have told her that the software works fine but they wish it could perform more functions.

“Our system does what it’s supposed to do,” Tate said.

She acknowledged that state officials are looking to replace PrepMod with a more comprehensive system, but that’s been the plan all along.

PrepMod, she said, was always seen by California “as an interim” program. She said she doesn’t know how much the state is paying her nonprofit for the software. Officials with the state Department of Public Health couldn’t be reached.

Confusion about vaccines at Cal Expo

Newsom had big news Monday: Cal Expo would open a giant vaccination center, along with Dodger Stadium, Disneyland and the San Diego Padres’ baseball stadium, Petco Park.

The problem was, Cal Expo was still limiting its shots to healthcare workers and wasn’t ready to vaccinate the masses. Soon after the governor spoke, the county had to issue a statement telling other would-be recipients to stay away.

“We are not currently vaccinating the general public at the Cal Expo location and will not be for quite some time,” the county said. “We request that both media and general public ... not attempt to access the location, for health confidentiality and security purposes.”

It’s not just Cal Expo; when it comes to getting vaccinated in California, confusion can often be the order of the day. Take what happened three weeks ago at a Sacramento area nursing home.

A nurse who works at the home said she and her co-workers collected consent forms and prepared residents to receive their shots. But when employees arrived from an area pharmacy to administer the doses, a brief bit of chaos ensued: Many of the residents had recently been given tuberculosis tests, a development that that the pharmacy workers feared could cause an adverse reaction with the COVID-19 shots. The nurse spoke to The Sacramento Bee about the incident on the condition that The Bee wouldn’t identify her or her employer.

The pharmacy employees gave shots to some of the residents but left most of them unvaccinated. Later that day, however, the pharmacy staff returned and said the others could get their shots. Employees at the nursing home had to then scramble to get the residents and their paperwork assembled again. The residents got vaccinated.

In many respects, policymakers and elected officials say confusion is evidence of a system struggling to cope with the resurgent COVID-19 pandemic. They say California’s decentralized approach to healthcare, in which much of the decision-making is done at the county level, has added to the problem, particularly in counties where doctors, nurses and other providers have been overwhelmed by the recent spike in infections.

“Counties are stretched really thin,” said Assemblyman Jim Wood, D-Santa Rosa. “Public health departments before COVID hadn’t been funded at high levels, didn’t have a lot of personnel,” he said. “I think it’s been slower than we would have liked because of challenges with personnel.”

Wood, a dentist, has helped administer vaccines around his legislative district, an experience that reinforced his belief that the state still has to improve the logistics of getting the vaccines into people’s arms. But he believes things will improve.

“I have new appreciation for how difficult this rollout really is,” he said. “I believe this a lot like an old steam locomotive: It takes a while to get the train moving down the tracks, but once it gets going, it gets going pretty fast.”

This story was originally published January 15, 2021 at 5:00 AM with the headline "California lags far behind the rest of U.S. in COVID vaccinations. What went wrong."