Earlier this month, shortly after Pfizer announced that its vaccine was 90% effective in preventing COVID-19 in a clinical trial, New Jersey physician Linda Girgis tweeted to her patients: “As a family doctor, I’m seeing whole families infected with #COVID19. Please #WearAMask and keep #SocialDistance. A vaccine is coming soon.” 

But despite her hopeful message, Girgis doesn’t think she’ll be able to administer the Pfizer vaccine to her patients. The much-awaited remedy comes with many logistical caveats. The vaccine is expected to be shipped in quantities of 1,000 to 5,000 doses and requires specialized freezers, which can range from $4,000 to $10,000 — too pricey for independent providers — because it must be kept at -112 degrees Fahrenheit. “I am in a small practice with my husband, and we don’t have the capability to store vaccines at this temperature,” says Girgis, who plans to refer her patients to a facility with more resources, possibly a pharmacy. “I think the cost is prohibitive for a lot of us.” Handling something that must be kept at such temperatures requires training, she adds. “I don’t think I’d be able to do it myself.”

Girgis is not alone in her concerns. Storing and administering such a vaccine presents logistical challenges for many small practices and rural clinics. Some won’t be able to afford the freezers. Others who typically order vaccines by dozens rather than hundreds won’t be able to use 1,000 or more doses. There are additional issues: Electricity supply in some regions of the nation is unreliable, and winter weather can make traveling to clinics difficult. The vaccine also requires two doses administered 21 days apart, so patients would have to travel twice to get immunized. So, depending on which states, territories and climate zones health providers are located in, the challenges they face are as diverse as their environments.

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Leah Gilliam, a family medicine specialist at a small primary care clinic in Lexington, Tennessee, a rural town about two hours away from major urban centers, won’t be administering the vaccine to her patients either. Her clinic provides low-cost care that serves many uninsured patients, so she can’t afford the freezers. “Small offices won’t be able to accommodate that, and I certainly can’t,” Gilliam says. Any vaccine storage is a challenge for small practices, she adds, even those that don’t require super low temperatures. Because small clinics don’t have many patients, the vaccines often go past their expiration dates, so Gilliam typically refers patients to the local health department. In her case, there’s one five minutes down the road, but this additional stop can be an obstacle, particularly with a two-dose vaccine. The drive itself is not a barrier, but it’s just another step the patients have to take, and lots of times they end up putting it off, Gilliam says. “They just never get around to doing it.”

Ever since the Pfizer announcement, Ann Lewandowski, the co-chair of the State Disaster Medical Advisory committee on vaccine distribution and founder of the Wisconsin Immunization Neighborhood, which works to reduce vaccination barriers, has been on the hunt for an affordable freezer that health providers can buy. “A small thermal shipper has been a task of mine,” she says. When Lewandowski found that AeroSafe Global freezers that can keep the vaccines at the right temperature sell for less than $1,000, it made her day.

Another bit of good news came when a Pfizer rep told her that the company’s thermal shippers should be able to sustain the vaccines for 20 days, as long as the dry ice in the package is replenished. Add to that an additional five days of thawed refrigeration, and the vaccine could be kept for a total of 25 days. That extra five-day stretch is key for the administering the second dose, Lewandowski notes. “If you are designing an immunization campaign, you can stock up enough vaccines so that everybody can get their two doses.” But Wisconsin’s rough winter weather will throw some kinks into the plans — mainly, some of the state’s older residents may not be able to drive to clinics. “We will need to find traveling nurses to provide to the elderly population,” Lewandowski says. 

In Vinita, a rural town of 5,000 people in Oklahoma, Melissa Gastorf, who works at a tribal healthcare system, says that the Cherokee nation plans to buy three or four freezers to keep at different clinics. Moderna’s vaccine, whose announcement came several days after Pfizer’s and is said to be nearly 95% effective, can be stored at standard refrigerator temperatures, a more appealing option for many healthcare providers. “The fact that it can be stored in a refrigerator makes it easier, especially for those clinics that give out vaccines on a regular basis,” Gastorf says — so they can use the existing fridges. Through their elders, the tribes typically get to have a say in their medication supplies and negotiate directly with pharmaceutical companies. “Usually we have a pharmacy committee that does the negotiations with different companies,” she says. Through a government-funded program, the tribes offer their own health services, so the members’ vaccinations will be covered, but getting to the clinics will be an issue. “Not everyone has a reliable means of transportation, and some don’t have any,” Gastorf says. The tribes’ health system has public nurses who could travel to people, but they would need to store the vaccines at proper temperatures while transporting them.

For others, even if they had the authority and ability to purchase the right equipment, issues with unreliable infrastructure become limiting factors. Maryal Concepcion, a family physician hired by the Physicians Network Medical Group Inc., who works at an Adventist Health clinic in Arnold, California, notes that buying freezers won’t guarantee the vaccines’ viability. Her clinic is located in the middle of Stanislaus National Forest, where dry air and wind periodically create fire hazards, forcing the local power company to shut down electricity. “The longest we’ve been without power was five days,” Concepcion says, which resulted in vaccine losses at her practice. The clinic had installed a power generator, but during a recent outage, it failed. “We had a generator, and we still lost vaccines,” says Concepcion, for whom a shelf-stable vaccine that doesn’t need to be refrigerated would make the most sense.

She would still have to worry about community trust, low in her area, in the vaccine. “I’m expecting a lower than 50% desire to even have the vaccine because in our county we have a significant amount of anti-vaxxers,” she says.

While the vaccine logistics can be overwhelming, the vials won’t start arriving at doctors’ offices overnight. Neither Pfizer’s nor Moderna’s vaccines have yet been granted emergency-use authorizations, although Pfizer has just announced it has the safety data to apply for it. Also, the first rounds of vaccines will be sent to hospitals to immunize their frontline workers, so the general population will start receiving them afterwards. That gives physicians some time to prepare and work with their local public health departments.

“How, when and where the vaccine is administered will depend on the vaccine that is authorized, who is recommended to receive it and when, and the individual jurisdiction plans for distribution,” Ada Stewart, a family physician in Columbia, South Carolina, and president of American Academy of Family Physicians, wrote in an email. The Centers for Disease Control (CDC) offers a “playbook” of operational guidance for jurisdictions by state, she adds. “Physicians should work with their local public health officials and the CDC to learn about their local jurisdiction’s plan and how their patients and practice will be affected.”

This article originally appeared on Medical Bag