Delivery of Care

The laws of supply, demand – and waste?

With the supply of COVID vaccines rapidly increasing in the U.S. and RI, the clamor for access has led to an avalanche of requests, overwhelming state signup websites, and creating issues around accountability – and alleged waste

Photo by Richard Asinof

The CVS Pharmacy at the Providence Place Mall had allegedly been involved in disposing of unused vaccines at the end of each day, according to several sources. Both the Governor's office and CVS said that every effort has been made to minimize any waste.

By Richard Asinof
Posted 3/15/21
With the growing increase in supply of vaccines, and the response by the state of Rhode Island expand the eligibility for vaccines, beyond the problems of managing limited supply and pent-up demand, what happens when a reporter, receiving a tip about alleged practices of disposing of unused vaccines by a large pharmacy, starts asking questions.
Was it a big mistake to leave out the proposal for a new public health laboratory in Rhode Island as part of the bond package approved by Rhode Island voters on March 2? What will be the response by Gov. McKee if the decision to loosen restrictions around small businesses backfires with an increase in new COVID cases in the coming months, despite the growing availability of vaccines? What do you tell a person you encounter at a store that is not wearing a mask? Is there a way to document with specific metrics how effective the vaccines have been in reducing the death rates from COVID in nursing homes?
One of the new habits created during the COVID pandemic has been the adoption of weekly briefings by the Governor, often featuring top administration officials, to amplify the messaging. It has allowed Dr. Nicole Alexander-Scott and Dr. Jim McDonald at the R.I. Department of Health to emerge as familiar faces if not media stars. At the same time, it has made it that more difficult, sometimes, to serve as an appropriate forum to ask questions.
For sure, the need for accurate, trusted information has shined a bright spotlight on Dr. Ashish Jha, the dean of the School of Public Health at Brown University, and on Dr. Megan Ranney, an emergency room doctor, who are featured almost daily on national cable news networks. Indeed, in the recent story by New York Times reporter Apoorva Mandavilli, “How Rhode Island fell to the coronavirus,” both Jha and Ranney were quote as experts at length, analyzing how “a dense population of vulnerable citizens set the stage for a frightening epidemic,” as it was phrased in the story’s subhead.
But what if Mandavilli had actually spoken with doctors on the front lines in those neighborhoods where “vulnerable” residents lived: Dr. Beata Nelken at Jenks Park Pediatrics in Central Falls, Dr. Andrew Saal, chief medical officer at Providence Community Health Centers, and Dr. Annie De Groot, the volunteer medical director at Clinica Esperanza? How would their insights have differed from those of Ranney and Jha?
Having interviewed all three doctors in the last year about their work, the missing part of the conversation around the delivery of health care in Rhode Island – and in the nation – is the ongoing failure of the health care delivery system to address the needs of the uninsured, the under-insured, and the immigrant communities. The voices of Nelken, De Groot and Saal need to be heard and made part of the larger conversation, in ConvergenceRI’s opinion.
Would Gov. McKee invite them to stage at a press briefing? Will Neil Steinberg, president and CEO of the Rhode Island Foundation, invite them to address the ongoing stakeholders group working on designing a 10-year health plan for Rhode Island?

PROVIDENCE – This is an evolving story, much as the genetic structure of a virus mutates. Warning: the plot line is filled with suspenseful twists and turns, much like finding an extra dose of vaccine “hidden” in the vial, and then rushing to put it into the waiting arm of a thankful resident, before the life of the vaccine expires and the vial is thrown away, unused. A vaccine is a terrible thing to waste.

On Thursday, March 11, President Joe Biden announced new ambitious goals to provide vaccinations to millions of Americans at an accelerated pace. At least 66 million people have received one or both doses of the vaccine in the U.S. as of Saturday, March 13, according to The Washington Post. More than 34.1 million people have been fully vaccinated, and some 133 million doses have been distributed, with more on the way.

Last week, approximately 2.3 million doses per day in the U.S. were administered, an 11 percent increase over the previous week, according to The Washington Post.

However, here in Rhode Island, in the last week, an average of 8,400 doses per day were administered, a 10 percent decrease over the previous week.

At the same time, R.I. Gov. Dan McKee announced an expansion in the range of Rhode Islanders that will now be able to gain access to getting one of three approved vaccines into their arms, for many a welcome pivot in strategy.

For Rhode Island, and for a nation now led by President Joe Biden, it is an attempt to move forward, like the axis of the Earth, with the Northern hemisphere now tilting back toward the sun, shifting toward light, toward rebirth, seeking a path out of the long COVID nightmare – one tragic year later, after more than 500,000 deaths.

McKee spent Friday, March 12, visiting local vaccination clinics as local cities and towns began administering first doses of COVID-19 vaccine to K-12 teachers, school staff, and childcare workers, part of an aggressive public relations effort to promote his change in vaccination policy to make teachers and school staff a priority – followed by a change in policy allowing people ages 60 and older and people with certain chronic medical conditions to get vaccinated.

In Rhode Island, the big problem was that demand easily outstripped supply: the new eligibility opened the access valves to the vaccine for more than 160,000 Rhode Islanders, but the state had only opened some 1,570 new appointments, according to Dr. Nicole Alexander-Scott, director of the R.I. Department of Health, as reported by WPRI-TV. Can you spell online “traffic jam?”

All of the available appointments “went very quickly – within an hour,” according to Joseph Wendelken, public information officer with the R.I. Department of Health, as reported by WPRI-TV. “At points just after 5 p.m., there were 400 to 500 people trying to book every second.” [Editor's note: Opening up the registry for vaccine appointments on a Friday night at 5 p.m. is a perverse strategy.]

Persistence or luck?
Dante Bellini, Jr. advertising man turned documentary movie maker, posted on Twitter Saturday morning: “Success! But man, making that vaccine appointment is like trying to nab letters of transit to get out of Casablanca,” showing a GIF image from the classic movie that starred Humphrey Bogart.

In contrast, in response to the posting of the WPRI story on Twitter, Tim Hopkins [@arquimedezpozo] said: “Registered yesterday [Friday] morning on CVS and it was easy. Got the shot today [Saturday] and they said they had a lot of no-shows so people should check CVS website randomly.”

In a follow-up tweet, Hopkins explained, in a response to Bob Kumins, who asked: “How’d you sign up? Every time I check their website, it says all locations are booked up. What am I doing wrong?” with: “It appears they add lots early in the morning [I went on around 6:30 am]. The lady who gave me the shot says they usually fill up within 30 minutes.”

To which @kjhop replied: “It would probably be more accurate to say you were lucky more [than] that it’s easy.”

To enable the teachers and others to gain access to the vaccine with the limited supply, Gov. McKee’s administration had taken control and redistributed some 14,000 vaccine shots that had been part of the unused supply contracted with private partners for nursing homes, including those provided to CVS.

In turn, CVS, blessed with an apparent “extra” supply of vaccines, opened up its pharmacy stores to dispense vaccinations, including to teachers, mirroring new national and state guidelines.

Stay tuned. There are more plot twists to come in this tale of supply, demand, and alleged waste, ones that defy traditional arguments around the value of public-private partnerships.

Warning signs still persist
Despite all the apparent good news on the vaccination front, the “engine” warning light keeps blinking on and off on the public health dashboard.

The science, however, remains a persistent if disliked fact: viruses keep being viruses, as Dr. Megan Ranney, MD, emergency room physician, tweeted out on late Friday night. Viruses are equal opportunity ambushers, changing form and mutating to seek new hosts, finding the path of least resistance. [Did you hear the joke about the  virus saying “thank you” to Texas Gov. Greg Abbott when he lifted the statewide mask mandate in his state?]

• At the University of Rhode Island campus in South Kingstown, a spike in COVID-19 cases has resulted in 64 percent of its isolation and quarantine beds being occupied, at a time when most students, staff and professors are not yet eligible to receive the vaccine, according to The Boston Globe.

• Gaining access to vaccines has revealed some significant gaps in racial equity and wealth disparities. Nationally, some 54 percent of people who received their first dose of the COVID-19 vaccine from community health centers were people of color – including 26 percent who were Hispanic and 12 percent who were Black, according to a chart prepared by the Kaiser Family Foundation. Those numbers starkly contrast with nationwide data, where 9 percent receiving on dose were Hispanic and 7 percent were Black.

• Here in Rhode Island, the work being done by Clinica Esperanza, the Providence Community Health Centers, and ONE Neighborhood Builders in reaching the uninsured and under-insured in the Providence neighborhoods hardest hit by COVID has succeeded, in large part because of the trust that residents have in these agencies to deliver. But there is still a scramble over limited vaccine supply.

• Similarly, in Central Falls, pediatrician Dr. Beata Nelken has proven to be the trusted go-to source for testing and for vaccinations, from her office on Broad Street, located right across from City Hall.

In a ceremony on Thursday evening, March 11, Central Falls Mayor Maria Rivera presented Nelken with a key to the city, honoring her as part of the celebration of International Women’s Day. [See link to story in this edition of ConvergenceRI.]

Often, at these clinics, there is a mad scramble at the end of each day, as providers attempt to match doses of vaccines and get them into the waiting arms of anxious residents, if there are any doses left over or unused. The limited supply of vaccines is still driving the “market,” and those with nimble texting skills often succeed in getting the vaccine.

Can you imagine how a hospital CEO might react, if the door accessing a vaccine did not swing open automatically for them? What GIF would they choose to attach to their post on Twitter, to express TFW they were unable to book an online appointment to get an “unused vaccine dose” at 5 p.m.?

Tossing unused doses?
So, when a reliable source told ConvergenceRI about an alleged practice at the CVS pharmacy store in Providence Place Mall throwing out unused doses of the vaccine when the store closed in the evening, it was troubling news. It was also a perplexing, sensitive story to figure out how best to follow up and to try to get some answers.

First, ConvergenceRI checked out the story with a second reliable source, to see if they had heard about the alleged practice of discarding unused vaccines by CVS at the Providence Place Mall; they indicated they had.

The next step, of course, to quote the lyrics from the theme song for the 1960s TV show, “Mr. Ed,” was to “go right to the source and ask the horse.”

First, ConvergenceRI contacted both the R.I. Department of Health and Gov. Dan McKee’s new press secretary Alana O’Hare, asking: “I have heard, from two reliable sources, that the CVS store at Providence Place Mall is throwing away vials of vaccines when the [store] at the mall closes. Is this accurate? Can you verify if this is happening? Thanks!”

O’Hare responded promptly on Wednesday evening, March 12: “On behalf of the R.I. Department of Health, we can say that all vaccinators have received clear guidance directing them to administer every available dose. Our waste rate is around .1 percent, which is exceedingly low. We do not know of any vaccinator regularly discarding vaccine.”

[The response, it turns out, may have been one of O’Hare’s last acts in her brand new job as press secretary for the next few weeks; she gave birth to a baby boy on Thursday, March 11, and will be taking a four-week leave, according to a story The Providence Journal. Congratulations, Alana! As O’Hare tweeted on Saturday afternoon, March 13: “I am thrilled to be joining the @GovDanMcKee team. So thrilled, in fact, that I went into labor early. But, I’ll be back!”]

The problem with the response by O’Hare, however, is that it did not answer the specific question asked. Yes, the state has given clear guidance to vaccinators to administer every available dose. Yes, the current “waste rate” is exceedingly low. And, yes, the state is unaware of any vaccinator regularly discarding vaccine.

But it did not address the question asked: Was the CVS store at the Providence Place Mall allegedly discarding unused vaccines when it closed?

O’Hare’s non-answer answer, in turn, raised more follow-up questions to ask. Having been made aware by a reporter about an alleged practice about the discarding of vaccines, what is the state’s response? Who specifically on the Governor’s team – and at the R.I. Department of Health – would be responsible for investigating the alleged disposal of vaccines? Is it Thomas McCarthy, executive director, COVID Response, at the agency?

Further, what accountability procedures exist for vaccinators? And, if it turn out there were “extra” vaccine doses not being used, how could the R.I. Department of Health attempt to coordinate a way to get those doses to other clinics on that same day, given that supplies of vaccines are still limited?

Your wellness destination
ConvergenceRI also sought out a direct response from CVS. Michael DeAngelis, Senior Director, Corporate Communications, responded promptly.

“We are committed to not letting any vaccine go to waste. In the event of unused doses, our pharmacy teams reach out to eligible patients in their communities and/or can vaccinate our own essential frontline workers,” he said.

In the event that is not possible, DeAngelis continued, “They use their judgment as health care professionals to help ensure every dose of vaccine is used. In the rare occurrence that any vaccine cannot be used while still viable, it is disposed of in accordance with CDC [Centers for Disease Control and Prevention] and manufacturer deadlines.”

Neither DeAngelis nor O’Hare denied that the disposal of unused vaccines was occurring. Why not?

And, after being alerted by the questions from ConvergenceRI about the alleged practice of disposing of unused vaccines at the end of day, was there a better strategy being developed? Is there an opportunity for CVS to coordinate with other vaccination clinics in Providence, such as Clinica Esperanza or Providence Community Health Centers, to make available any potential extra doses of the vaccine?

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