Nurse administers a vaccine
A nurse administers a vaccine. National Cancer Institute.

Just before noon Monday, Dr. Katie Passaretti stood still while a nurse stuck a needle in her arm and injected a dose of cold liquid.

Then Passaretti, the medical director of infection prevention at Atrium Health in Charlotte, stood in front of a cellphone and made a video.

“So, I just got my first COVID vaccine, the first one at Atrium,” Passeretti, donning clear protective eyeglasses and a teal face mask, told the camera. “It feels perfectly fine.” 

Although Passaretti shared her story publicly, most hospitals have provided few specifics about the other health care workers who will receive the state’s first COVID-19 vaccines this week.

An informal survey of about three dozen hospitals and health care systems in the state by the N.C. Watchdog Reporting Network found plans to roll out the vaccine are still largely in flux as administrators work to pin down the arrival and volume of shipments and schedule high-risk employees — on a volunteer basis — for inoculation. Some hospitals provided few details on their plans; others didn't respond at all.

But their responses overall highlight the complexity and inherent uncertainty that comes with the massive logistical challenge of distributing a new vaccine amid a raging pandemic. State data shows more than 2,700 people are now hospitalized with COVID-19, a record since the first case was reported in the state in early March.

State leaders say they're trying to pull off a delicate balancing act, getting a finite amount of the vaccine to people who have the most need for it in every corner of the state — without sending too much to any one place and having doses go to waste.

And they're relying largely on hospitals to execute the first phase of that plan: the vaccination of 85,800 health care workers at highest risk for contracting the virus.

Nobody can know exactly how effectively the state’s strategy is working until after tens of thousands of doses have been administered. That means state health officials are watching the rollout closely and collecting data to indicate where adjustments need to be made.

“We're going to have to adjust, and it's going to be hyperlocal as we go, which is why the data is going to be important as we get into this,” N.C. Department of Health and Human Services Secretary Dr. Mandy Cohen said of the work her staff will be doing to make sure the state’s vaccine distribution is effective.

‘Things are a bit unclear’

The first shipments of the COVID-19 vaccine made by Pfizer were scheduled to go to 11 hospitals scattered across the state, selected because they had enough storage space to keep the vaccine at the required subzero temperature for up to two weeks. 

“Essentially, if you were a health care entity, or hospital entity, and you had this freezer space, you got on the list,” Cohen said.

The list includes some of the largest hospital systems in the state: Atrium Health, based in Charlotte, Wake Forest Baptist Medical Center and the UNC Health system. But smaller hospitals, including Cape Fear Valley Medical Center in Fayetteville and Pardee Memorial in Hendersonville, were also on the list.

Other large hospitals, including Novant Health, did not receive a shipment in Monday’s initial distribution because they could not guarantee enough storage capacity for the full two-week period.

“We weren't sure how long they would actually need to store before they actually get the vaccine into arms,” Cohen said. “So, we basically just said, ‘Anyone who could meet these specs, you're on the list.’”

The Pfizer vaccine is being shipped to North Carolina from its Wisconsin and Michigan locations. UPS and FedEx are shipping the frozen vials in specialized temperature-controlled thermal boxes, which maintain the necessary minus 94 degrees Fahrenheit for up to 10 days unopened, thanks to the two layers of dry ice.

The Pfizer-manufactured thermal boxes can serve as temporary storage units for up to one month if needed as long as the dry ice is replaced every five days.

A day after the centers receive the vaccines, UPS Healthcare President Wes Wheeler said, the company will mail around 42 pounds of additional dry ice, which the CDC says is about the necessary quantity to maintain the required freezing temperature. At its peak, Wheeler said at a White House summit last week, the company will be mailing between 60,000 and 70,000 pounds of dry ice each day.

Once ready to use, the vials can be stored at the same temperature as a common household refrigerator, between about 36 and 46 degrees Fahrenheit, for five days.

Once the shipments arrive, there’s variation in how systems are distributing the vaccine.

For example, in addition to the medical center in Chapel Hill, some UNC Health-affiliated hospitals will receive direct shipments as well, while WakeMed Health and Cone Health planned to keep initial doses at the flagship hospitals.

But as these first 11 hospitals received their shipments Monday, how they would distribute the vaccine remained unclear.

When contacted by reporters late last week and again Monday for details, many hospitals gave little information or responses.

In some cases, hospital spokespeople said they were unsure of the details.

Wake Forest Baptist Health said in a statement Monday the medical center received 2,925 doses and that the vaccine would go to front-line health care workers. But a spokesman for the hospital, Joe McCloskey, didn’t answer questions directly early last week, saying that “specifics are a bit unclear right now.”

“Wake Forest Baptist Health plans to follow a phased vaccination approach, aligned with federal and state guidance, to prioritize our health care workers based on likelihood of exposure,” McCloskey said. “Hope to know more in the coming days, but that’s what I’ve got for now!”

Among the other responses from hospital spokespeople:

  • In Elizabeth City, Sentara Albemarle Medical Center, which is managed by a Virginia-based company, will receive its first shipments at Sentara Norfolk General Hospital, through Virginia’s health department. 
  • Iredell Memorial Hospital and Hugh Chatham Memorial Hospital, in Elkin, are each slated to receive 975 doses of the vaccine this week.
  • UNC Health Southeastern in Lumberton, formerly Southeastern Regional Medical Center, plans to vaccinate about one-third of its workforce over the next four weeks with its initial 975 doses.
  • CaroMont Regional Medical Center in Gastonia is expecting 1,950 doses and, like many other hospitals, will allow staff deemed to be a priority to opt in to receiving the vaccine.
  • Vidant Health, based in Greenville, is another hospital system expecting a shipment of the Pfizer COVID-19 vaccine later this week. Records show the hospital has been allocated 2,925 doses. Spokesman Jason Lowry said the hospital expected to administer the vaccine to staff, and not community members, “for some time.” 

State lets hospitals decide who gets first doses

Ahead of distribution, North Carolina officials laid out a basic framework for who should get the vaccine first. Hospitals were instructed to prioritize staff who are exposed to COVID-19 the most and then those who would be most adversely affected by contracting it.

But within that framework, hospitals have leeway to decide whom exactly to vaccinate first.

“We've left that to the hospitals,” Cohen said. “We attempted to start to think about that rabbit hole and then recognized that every hospital is, you know, so different.”

Hospitals have been encouraged to stagger their injection schedules to allow for any of the potential side effects of the vaccine, such as injection site soreness, fatigue and other symptoms.

“We have to stagger this because if, you know, folks feel crummy for 24 hours, we don't want folks calling out all at the same time, and then we don't have anyone to staff the hospital,” Cohen said. “So, they're trying to be thoughtful now.”

At Novant’s Brunswick Medical Center, President Shelbourn Stevens said the facility is encouraging staff members to get their vaccine the day before a day off and are having people sign up so that the order can be monitored.

After the first round of vaccine is delivered to the 11 hospitals, a second shipment of vaccine will arrive later in the week to a much longer list of 42 hospitals, including Novant. Many of those sites either indicated too late that they had the required long-term storage space to be included in the initial shipment or have far less storage capacity.

Shipments of the Pfizer vaccine, Cohen explained, contain 975 doses per package, but not all hospitals in the state need that many in the first phase — especially rural medical centers.

“We don't want vaccine, obviously, sitting or sitting around,” she said. “We wanted to make sure we were concentrating on sending these 975 units to places that could use them in the first week.”

This strategy means some hospitals in the hardest-hit areas, such as Columbus County, won’t receive doses in the first rollout.

However, Cohen said it won’t be long before the urban-rural divide is rectified.

“The plan will be to be in all 100 counties through our local health departments and hospitals by week two, assuming all the other things go right,” she said. “So, we are only talking about a week difference.”

While the Pfizer vaccine goes to hospitals in the initial phase, the Moderna vaccine, should it also be approved by the Food and Drug Administration and Centers for Disease Control and Prevention, will be distributed to Walgreens and CVS to target nursing homes and other adult care facilities.

Once the state receives its allocation of the vaccine, Cohen said, it will in turn allocate doses to the pharmacies, which will set up appointments and clinics with the congregate care facilities to begin vaccination.

Assuming Moderna gets clearance, she anticipates that process will begin next week and into the week after Christmas.

The Moderna vaccine has a slightly different distribution process. McKesson, a pharmaceutical distribution company, will receive the vaccines and coordinate its delivery through UPS and FedEx, which will ship them to the chosen locations along with kits of ancillary supplies.

Each kit will include vaccination record cards, needles and syringes, surgical masks and face shields for the vaccinators, alcohol prep pads and vaccine needle guides detailing specific procedures according to the patient’s age, weight and gender, according to the CDC.

Moderna expects its vaccine to keep at a significantly higher temperature than the Pfizer vaccine, at minus 4 degrees Fahrenheit, the same temperature as most medical freezers, for up to six months. After thawing, the vaccine can be kept at standard refrigeration temperature — between about 36 and 46 degrees Fahrenheit —for up to 30 days within the six-month shelf life. 

When it comes to oversight, Cohen said, state health officials are learning as they go, but they will require distributors like CVS and Walgreens to account for doses they’ve given to patients.

“Before we allocate any more, they have to show us, well, how much have you used? Where has it gone?” she said. “It's not sitting on some shelf there. You’ve got to use what we've given you before we give you more.”

Still, Cohen said, it’s a process that is evolving by the day.

“We are going to have to adjust, go back and figure out how to make sure that we are getting everyone,” she said.

Who gets vaccinated first?

Hospitals that did respond to questions for this story indicated the vaccine would first be given to front-line health care workers who are most likely to be exposed to the virus.

Charlotte-based Atrium Health, where Dr. Passaretti received the first COVID-19 vaccine, hasn’t provided a breakdown of which of its many hospitals were slated to get the first vaccine shipment. A total of seven Atrium facilities are expected to receive a shipment of the vaccine that is scheduled to arrive as early as Thursday.

A spokeswoman for the health system said in a release Monday that workers in the emergency room and medical intensive care units will get priority. Pressed for more details on the hospital system’s distribution plan late Monday, a second Atrium spokesman could not provide them.

Tatyana Kelly, a vice president and spokeswoman for the N.C. Healthcare Association, said hospitals are doing their best to address the most urgent needs first.

“What they're not going to be doing is vaccinating employees that aren't patient-facing, because it really is health care workers that are patient-facing, and those environmental services folks, etc.,” Kelly said. “So, if you're working from home doing paperwork, you may not be in the first couple of weeks.”

A Novant Health spokeswoman said the health system anticipated receiving its first doses of the vaccine on Thursday, though the timing remained in flux.

Like Atrium, Novant has a number of hospitals across its system. Spokesperson Megan Rivers said Novant Health Presbyterian Medical Center in Charlotte would receive nearly 3,000 doses in the system’s first allocation and nearly 7,000 doses total. Novant expects to be able to vaccinate at least 6,825 of its 29,000 employees by year’s end, Rivers said. 

But Rivers, like other spokespeople, could not give more specifics about which employees would receive the first doses of the vaccine.

Many hospitals did say, however, they would prioritize employees who work directly with COVID-19 patients or have a higher risk of exposure to the virus.

Duke Health provided some specifics, saying it has identified 5,000 of its 20,000 employees as eligible to get the vaccine first. That cohort includes emergency staff as well as personnel in COVID units, respiratory care centers and urgent care centers.

Asheville-based Mission Health’s system spokeswoman Nancy Lindell said Tuesday that the hospital will not deviate from CDC recommendations about who should get the vaccine first.

“We’re not deviating from those at all,” Lindell said of the CDC recommendations. “Although it is our right to do so, we’re looking at it and saying, ‘You’re right, that’s the way to go.’”

Mission also has an assisted living facility based on the campus of Highlands-Cashiers Hospital, where some of the vaccine will also go.

In addition to health care workers, including doctors and nurses, vaccinating environmental and cleaning staff should also be part of the initial rollout plan, Kelly, of the N.C. Healthcare Association, said.

“It's really important to protect them just as much as someone that is providing clinical care, because they are just as close to the exposure as the people providing clinical care,” Kelly said.

This story was jointly reported and edited by Kate Martin, Laura Lee and Frank Taylor of Wmforo; Ames Alexander, Gary Dotson and Gavin Off of The Charlotte Observer; Chiara Vercellone, Jordan Schrader, Tyler Dukes and Lucille Sherman of The Raleigh News & Observer; Nick Ochsner of WBTV; Emily Featherston of WECT; Ali Ingersoll of WRAL; and Jason deBruyn of WUNC.

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The NC Watchdog Reporting Network is a cooperative effort of investigative journalists representing seven news organizations across North Carolina. Participants include Wmforo, the Charlotte Observer, the News and Observer, WBTV, WECT, WRAL and WUNC. Email CPP's news team at [email protected] to contact the NC Watchdog Reporting Network.

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