When the St. Louis County Department of Public Health saw itself listed among the hospitals expected to receive thousands of vaccines last week, it came as a surprise.
No one had told the health department or hospital systems that was the plan, or even what that meant — setting off days of confusion over where the department was supposed to get its vaccine doses.
“What it has meant,” said Christopher Ave, spokesman for the county’s department of public health, “is that we have received no doses from the state.”
Meanwhile, in some rural counties, health agencies mistakenly administered vaccines that were intended to be booster shots, citing confusion about guidance to not hold back and get shots in arms.
The state has rushed to address these communication breakdowns with local public health providers, announcing increased doses for the St. Louis region on Thursday and laying out steps for vaccinators in a call earlier in the week on how to handle supply chain issues arising from booster doses.
But in the scramble to roll out the largest vaccine program since polio, and with supplies still limited, the state’s vacillating directives are leaving local providers tasked with carrying out the state’s plan unclear as to how to do so.
“We’re all at the whims of the state,” said Alex Garza, the incident commander of the St. Louis Metropolitan Pandemic Task Force.
Confusion has been present since the early days of the state’s rollout, like in December when Clay County hospitals’ expected shipments were canceled and they struggled to get answers as to why.
Meanwhile, when the state announced its expansion of people eligible to receive the vaccine last month, local public health departments said they only found out a few hours before — and past the deadline to order more doses to be able to serve the anticipated influx of eligible residents.
If “the governor is going to make some big announcement, we’ve made it abundantly clear, you make sure we know it before he spills it all over the news waves,” said Audrey Gough, the administrator of Shelby County Health Department. “Because we haven’t got time to be blindsided.”
The lack of clear communication trickles down to residents trying to get their turn at a finite amount of vaccine, as appointments are put on pause and new waiting lists add to the growing inventory of places to put their names down.
“There’s a lot of moving parts to this every day, but the one thing I want to assure the public is that nobody will get treated any better than anyone else,” Gov. Mike Parson said during a press conference Thursday. “We will make sure that distribution is evenly and we have done that at this point. And it is a very complicated thing to do, but we continue to do it.”
As of Friday, 9.7 percent of Missouri’s residents had received at least the initial dose — ahead of 13 other states, according to the Washington Post.
In places like Shelby County in northeast Missouri, the current system has been working — as evidenced by their position as one of the top counties leading the state with 18.1 percent of their residents already receiving a first dose.
But Gough said she still has to stay on her toes to keep up with quickly changing guidance.
“If you miss one conference call, you better be listening to the recording pretty quickly,” Gough said.
When the St. Louis County Department of Public Health was listed as a “high throughput” location, that set off a string of questions for Garza.
“Does this mean that St. Louis County is considered a high throughput center? And do we need to include them in our distribution plan?” Garza said. “And we were told no.”
But by the end of the week the expectation had changed — with the state telling the county health department its doses would have to come out of the hospitals’ allocation, rather than to the county directly.
“The state has both promised us doses and canceled orders,” Ave said. “And that’s happened repeatedly.”
It was a point Adam Crumbliss, the director of the Department of Health and Senior Services’ Division of Community and Public Health, acknowledged in a call with reporters Wednesday.
“We apologize for any confusion or error that that may have led to in the public realm,” Crumbliss said.
On Thursday, Parson announced the St. Louis County Department of Public Health would receive a direct shipment of 3,000 doses starting next week.
But Garza said the bigger issue is that the state needs to allocate its weekly supply proportionally based on population. That’s what the state was doing for the roughly 40,000 doses going toward high throughput hospital systems. Garza said it wasn’t clear that was happening for the state’s total weekly allocations.
“We don’t have any visibility on how those allocations are being made,” Garza said Tuesday.
During a press conference Thursday, Parson pushed back on Garza’s comments.
“If you start from day one when the vaccine started, St. Louis region has received their 37 percent — especially when you count the elderly and the nursing homes involved in this,” Parson said.
Around the same time Parson was denouncing Garza’s statements on Thursday, Crumbliss outlined for a St. Louis Board of Alderman Health and Human Services Committee meeting how many St. Louis city residents had received their first dose according to the state’s dashboard that day — 6.6 percent.
“As we’re looking across the data, one of the things that that certainly points to for us is that we need to make sure that we’re engaging more in the city of St. Louis to continue the vaccine distribution,” Crumbliss told the committee.
With Missouri’s allocation of vaccine increasing to about 97,525 doses for the week of Feb. 15, the portion going toward the St. Louis region’s “high throughput” hospital systems also increased to 21,000 doses.
Overall, the region, which makes up about 37 percent of the state’s population, will be receiving about 33,200 doses — or about 34 percent of the week’s supply.
Like the St. Louis County Department of Public Health, the Jackson County Public Health Department also hasn’t had its order requests approved by the state for about three weeks.
Children’s Mercy redistributed a portion of doses to the department, and Kayla Parker, a spokeswoman for the Jackson County Public Health Department, said they are working with counties in the region to receive a portion of the 2,500 doses allocated to local public health departments for next week.
“What may show today to be a low spot for one community may very well show to be a high spot for that same community a week later,” Crumbliss told reporters Wednesday, “and so we can see a lot of ebb and flow in those numbers.”
There’s also been some confusion around the second booster dose sent to vaccinators, including how to know whether a shipment contains booster doses and when to give them out.
Some providers have mistakenly given out booster doses as the prime dose, the state said on a call with vaccinators this week.
Gough said the Shelby County Health Department hasn’t run into that issue, but other health departments did “based on what they were hearing from either the national level or the state level, you know, ‘Once you get it, give it. Put it in arms.’”
In those cases, the state can’t guarantee there will be another matching dose available.
Guidance shared on a call with vaccinators Tuesday noted that due to supply constraints and a commitment to equitable distribution, if a vaccinator mistakenly “administers a large number of boosters as primes, they will need to solve the problem internally.”
It’s unclear how widespread the issue may be. Ted Delicath, a principal with the McChrystal Group, a Virginia-based consulting firm hired to advise the state’s response to the pandemic, told vaccinators that the state has seen these instances pop up, leading to “several hundred vaccines that the state simply does not have the ability to fulfill.”
Larry Jones, the executive director of the Missouri Center for Public Health Excellence, said he believes it’s an isolated issue — and not unexpected.
“Anytime you’re working with new systems, there’s going to be some confusion,” Jones said, “and at times lack of communication.”
Gough said providers have been told to delineate when a shipment is for prime doses versus booster doses, based on when they arrive.
It wasn’t until this month that providers could submit order requests for prime doses through an online form, instead of emailing them in each week — which had sometimes left providers unsure if their requests had been received.
The state submits order requests for booster doses on providers’ behalf, and guidance shared Tuesday said confirmation emails for shipments note which dose it is for.
In addition, the state clarified that prime doses arrive Tuesdays, while booster doses typically arrive Thursdays.
But in more rural areas, Gough said it could be easy for a shipment to be delayed — especially in winter weather. DHSS has created a chart for providers to use to help them track their shipments.
“If you’re not keeping track of that, it gets extremely confusing,” Gough said.
‘This is not a contest’
Despite it all, in some parts of the state the plan is working — with a few hiccups along the way.
In Audrain County, local officials had roughly a week’s notice to prepare for their first mass vaccination event with the Missouri National Guard.
Chris Newbrough, a spokesman for the Audrain County Health Department, said they first received word Thursday, Jan. 21, that the county may be chosen as a site, secured the Mexico Memorial Airport by that Monday and four days later, vaccinations were underway — with some eager residents arriving the night before to camp out in their cars to hold their spot.
“We were very pleased with how it turned out,” Newbrough said. “To come together with over 20 agencies in the county, in a total of three and a half days, essentially, to plan this.”
Newbrough said it would have been helpful to have more time to prepare — but they worked with what they had.
Lessons were learned, like traffic issues causing vaccine to arrive at the site late and making sure to have a way to shuttle primarily elderly people waiting in line to the bathrooms so they wouldn’t have to walk several hundred yards from their cars.
Despite having over 2,000 people on a wait list, the time constraint simply didn’t allow for registering people ahead of time to schedule appointments, Newbrough said. Some people described waiting in line for over four hours.
But their waitlist came in handy when they had about 100 doses leftover at the end of the day that would expire if they weren’t given, and again a few days later for about 400 extra doses. The health department blasted out an email to residents at the top of the list, letting them know to come to the health department.
“They were jovial. They were joking,” Newbrough said of residents. “They were in a good mood because they were getting a vaccine.”
It’s a feeling Gough has been proud to help bring to residents in Shelby County.
“It’s just a truly great day in public health — finally. We’re not the bad guy, we’re finally the good guy again,” Gough said, later adding: “We’ve taken a lot of abuse — I’ll just be blunt — from the public regarding what we’re doing, why we’re doing it, which has led to legislation being proposed to take away things.”
Early on, the region collaborated with the Samaritan Hospital in Macon, who bought a freezer that could store Pfizer’s vaccine at the ultra-cold temperatures needed. From there, Shelby County and providers in the region worked together to divvy up shipments to vaccinate frontline healthcare workers.
Since then, the department has received more shipments. And with the Hannibal Regional Hospital serving as a “high throughout” location that receives 1,300 doses weekly, that’s helped alleviate the strain on public health department’s like Gough’s.
“And we’ve told people, ‘Don’t wait on us. Get on our list. Get on Hannibal’s. Do what you got to do to get a vaccine in your arm,’” Gough said, “because this is not a contest. We just want to get vaccine in people.”