Future Tense

How Should Pharmacies Handle Extra Doses of COVID-19 Vaccine?

Vials of COVID-19 vaccine.
Once vaccine is thawed, it can go in someone’s arm or in the trash. Scott Olson/Getty Images

On Sunday evening, Liz Ruskin decided she’d procrastinated her grocery shopping trip long enough and dragged herself to the nearest Safeway. She made her way through the crowded aisles, annoyed she hadn’t mustered up the will to shop earlier, when it might have been quieter. As she was reaching for canned sockeye salmon, a voice came over the store’s loudspeaker. “They made this announcement that the pharmacy had leftover vaccine—I think the term they used was ‘extra vaccine’—and that if you were interested in getting a vaccine, you should go to the pharmacy.”

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Before the announcement was finished, Ruskin was already walking toward the pharmacy, cans of salmon and coconut milk still in her hands, and queued up in a line with about 15 other people. The dominant mood, she said, was excitement, but she also wondered whether what she was doing was right. Ruskin, a Washington correspondent for Alaska Public Radio, is 55, and she knew she did not belong to any of the groups currently eligible for vaccination in the D.C. area. She looked up and down the line, wondering if there were other people who should cut in front of her. “I would’ve given up my place to someone who was more vulnerable,” she says. “But it seemed like the right thing to do—if they were throwing vaccines away, and the pharmacy was closing, those should go in someone’s arm.”

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Since the Pfizer and Moderna vaccine rollout began in December, there have been reports across the country of providers ending up with vaccine doses they need to use up right away. In some cases, this results from vials containing “extra” doses—for instance, each Pfizer vaccine vial is designed to hold five doses, but many contain six, and Moderna vials are designed to hold 10 but many contain 11. In other cases, like what appears to have happened at Safeway the night Ruskin received her vaccine, providers must thaw a certain number of vaccine vials for daily appointments, but people who make those appointments may not show. Whether doses are “extra” or “leftover,” these situations require providers to make quick decisions about what to do with them; unthawed doses are only good for a few hours at room temperature. Amid an already chaotic vaccine rollout, it appears there’s little official guidance on what providers should do with these doses.

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In some cases, policies—or confusion over how to comply with them—have led to doses thrown away. After Stat reported in early December that one in six doses of the Pfizer vaccine were discarded because it was unclear whether “extra” doses in vials were usable, the Food and Drug Administration issued official guidance clarifying that those doses could indeed be used. And in some areas of the U.S., local and state public health guidance requires providers to use extra doses on groups eligible for vaccination, leading some providers to throw away doses if they can’t find people from those eligible groups. In a particularly dispiriting account published in the New York Times, a nurse called a nursing home, an urgent care center, and a women’s shelter and even ventured out on foot to administer vaccines at those locations, but ultimately, doses still went to waste.

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As the nurse’s story shows, the logistics of finding adults eligible for the vaccine at the last minute are difficult. It appears that in some cases, providers are taking a broader approach, vaccinating people who just happen to be in the right place at the right time, regardless of eligibility. These stories have popped up across the country, like the couple at a Louisville, Kentucky, Walgreens who got “the best Christmas present ever” with surprise vaccinations on Christmas Eve, and Houston residents who have hung around vaccination sites for extra doses. Franck Le Bousse, an architect living in D.C., was also vaccinated at a Safeway, exactly one week before Ruskin. But Le Bousse says there was no announcement; he was in the store to buy milk and cookies and just happened to notice a few people queued up next to a table with COVID-19 vaccine paperwork. He assumed they were in line to get on a waitlist for months down the line, but when he asked someone in line, they said they were waiting for extra doses. Just as Le Bousse approached the pharmacy counter to ask for more details, an employee emerged from a backroom. “The practitioner just came out and said there are 16 doses available, and since there were four of us in line, he said that means you’re going to get it.” Le Bousse immediately called his wife, who rushed to the store in time to receive one of the other extra doses that evening.

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When I called the Safeway where Ruskin was vaccinated, the pharmacy employee I spoke with denied that they were keeping a waitlist or giving extras to people shopping in the store and declined to answer additional questions. I contacted Safeway’s public relations department, which did not respond to my specific inquiries about the situation. The D.C. public health department also did not respond to a request for more information about the area’s policies on using extra doses or comment about Safeway’s closing time vaccinations. Similarly, none of the providers I contacted want to speak about this on the record, since the policies are unclear and the optics are bad: It could be damning to admit you’re vaccinating people who aren’t eligible per state guidelines, but it’s also damning to admit you’re throwing unused vaccine doses away.

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What’s resulted is a whisper network of places you might find extra vaccines. In D.C., residents are joking about hanging out at pharmacies around closing time, and comments in local blogs discuss which locations offer waitlists or closing time vaccines. (In fact, Ruskin tells me that the day after she was vaccinated, her husband went back to the same Safeway and they told him how to register for a waitlist.) Here in Seattle, I contacted my county health department for information about local policies on extra vaccine doses, but did not receive a response; meanwhile, I have heard rumors about an organization keeping a waitlist through a friend of a friend, and other friends around town have told me about family members or distant acquaintances who might have connections to doses that might otherwise go to waste.

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It’s no surprise people are looking for ways to get the vaccine, especially amid this slow rollout—and arguably, if the alternative is throwing out doses, it’s preferable to vaccinate anyone. But in thinking about who is most likely to have access to these whisper networks, or who has the time to, say, camp out at your neighborhood Safeway in hopes of scoring a vaccine, it’s likely the most privileged among us. Even in cases where folks have “won the lottery,” as Le Bousse put it, by being at the right place at the right time, there are invisible elements of circumstance at play: Pharmacies are less likely to be in underserved communities, for instance. Without plans and clear guidance for how to handle these extra doses, providers are left to use their best judgment on how to distribute leftover vaccine doses, and may feel some pressure to keep it all on the down low if state or local guidelines aren’t clear.

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Meanwhile, the lucky recipients of those extra doses are beside themselves with joy. Le Bousse says he felt hope after getting his vaccine—that this could be the light at the end of the tunnel. Ruskin, too, said she never dreamed this could happen to her and is amazed that she might soon have a ticket out of the pandemic, just because she procrastinated grocery shopping on a Sunday night. But alongside that elation, she’s still mulling over whether she may have taken someone else’s spot. That first shot was going to get thrown away if she didn’t take it, but what about the second booster shot she’ll need to get? “I don’t know who’s ahead of me or whose spot I’m taking,” she says. But when she made an appointment for the second shot in early February, she was reassured to see that all the time slots were open, suggesting she wasn’t competing with others for the supply. “If I’m in line on Feb. 7 and they say, ‘We don’t have as much as we thought,’ or ‘We haven’t finished vaccinated nursing home residents,’ I will go back to my place in the line and be happy.”

Future Tense is a partnership of Slate, New America, and Arizona State University that examines emerging technologies, public policy, and society.

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