What went wrong with the vaccine rollout in Alabama and what happens next

Daphne Crocker, 73, watched the line of cars in front of her pulling away from the Daphne Civic Center. A police officer came to her window to ask if she and her 78-year-old husband had a COVID-19 vaccination appointment. She did not, because she had called and was told to just show up for a shot.

“How can I obey what I’m supposed to do as an American citizen without proper prior planning?” she said. “They need to get their act together. They’re not doing an adequate job right now.”

The Crockers went home frustrated. The officer told them to call at 6:45 in the morning on a Tuesday or Thursday to get a same-day appointment.

“I will never get through,” said Crocker. “Everybody will never get through.”

As a highly contagious new variant of COVID-19 spreads throughout the country and the death toll surpasses 400,000, states are under extreme pressure to get shots into arms to protect overwhelmed hospitals and save lives.

Yet this month, Alabama’s vaccine rollout was ranked last nationwide by the CDC. The state still has no centralized online portal for people to sign up for vaccination. Hospitals statewide lack vaccine supply. The rollout is highly disorganized in some cases, like in Shelby County, where the public arrived to get vaccinated only to find an empty building.

The state itself doesn’t know how many vaccines it has given out. The Alabama Department of Public Health, the agency in charge of the rollout, says it lacks data on shots on the ground due to a technological glitch.

“We want to do a better job,” State Health Officer Dr. Scott Harris told AL.com earlier this month. “There’s a lot of pent-up demand out there, and we understand why people are frustrated.”

Slow start

Alabama began its vaccine rollout in December, with a painstakingly mapped-out plan from a panel of top scientists at the CDC. First in line for the vaccine would be those among the most vulnerable: frontline healthcare workers and nursing home residents.

On December 15, the first shots were given to a pair of doctors in Dothan.

“I’m hopeful that more people are able to take the vaccine so we can begin to see a decline in the number of critically-ill patients and families impacted by this disease,” said critical care nurse Donna Snow, the first to get the shot in Cullman.

Alabama immediately began administering its first 41,000 doses of the Pfizer vaccine to frontline workers in 13 hospitals across the state. Each was equipped with the ultracold freezers required for the vaccine.

But already there was trouble.

The state’s initial shipment was one tenth of what Alabama had hoped to get from the Trump administration to cover about 300,000 healthcare workers. Alabama’s second Pfizer shipment was reduced at the last minute, leaving public health officials scrambling to reschedule vaccine appointments with healthcare workers on the cusp of the holiday.

Darin Smith, 55, is an ICU nurse at UAB who received his first round of the vaccine December 18, easing some of his worries for his own health and for his mother who is in her 80′s.

“I (was) scared of getting a bad case of COVID-19,” he said. He imagined going on a ventilator and not coming off, like some of his patients. “I worried about when would be the last time I would be able to understand what’s going on.”

In Alabama, health experts welcomed the vaccine as an extraordinary advance.

“What that’s going to mean for us is an end to the pandemic,” said UAB infectious disease expert Dr. Michael Saag last month. “But we’ve got to make it until then.”

Vaccine reluctance

But even with much of the year to prepare for this moment, the logistics were daunting.

While larger urban hospitals like UAB were able to administer thousands of vaccine doses shortly after ADPH delivered them, others in rural parts of the state lacked the nursing staff to manage a large-scale vaccination campaign while struggling to keep up with the demands of expanded ICU clinics filled with COVID-19 patients.

At Lake Martin Community Hospital in Dadeville, nursing staff are able to administer about one vaccine every 15 minutes, about 30 to 40 people a day. “It’s very time consuming,” said hospital spokesperson Heidi Smith. “Nurses are in shortage, so we just have to give as many (vaccines) as we can schedule.”

And then Alabama ran into a more surprising problem. Even among medical workers, not everyone was convinced they should get the jab.

“I will probably observe for a while before I jump on board,” Rebecca Willis, a nursing professor at Jefferson State Community College, told Al.com in December.

Willis was not alone. In November, the CDC reported only 63 percent of healthcare workers said they will take a vaccine. In Alabama, an early poll of hospital staff showed half would take a vaccine at USA Health in Mobile and East Alabama Medical Center in Opelika.

At Athens-Limestone Hospital in Athens, administrators told AL.com that just 45 percent of hospital workers have opted to get a vaccine so far.

Alabama stumbles and then expands eligibility

By the new year, distribution was lagging. Alabama began appearing on national lists of the states vaccinating the fewest people.

Alabama decided to more than double the pool of people eligible for vaccination to include those 75 and older and emergency first responders. This meant stepping away from the original vision laid out by the CDC to carefully vaccinate the most vulnerable groups, one tier at a time.

Many states are heading in the same direction, speeding up and setting aside the original designs of tiers. Even the CDC is now recommending states skip ahead and vaccinate people 65 and above, a group that was in the third tier.

But Dr. Harris said adding people can create more problems, especially if the state doesn’t have enough doses for all of them.

“When you add extra groups that suddenly become eligible, it creates an expectation on the part of those people that not only are they eligible, but there’s also vaccine for them, right now for them to go get today and unfortunately that’s not the case,” he said.

No online portal

Alabama was caught unprepared for the expanded rollout.

As it announced the inclusion of more groups, the department launched a call center for vaccinations and said a sign-up website would come soon. Within two days, the state’s hotline was flooded with millions of calls. Hospitals statewide faced a barrage of communication from elderly residents desperately seeking the vaccine.

Harris said this week that the state hotline is run by a vendor with 165 phone lines, but still at times can’t handle the volume of calls.

“We are working to improve our registration capabilities by creating an online portal in addition to the hotline,” Alabama Governor Kay Ivey said in a Tweet January 11. “We’ll provide more info when that’s available.”

Five days after the state opened vaccines to 75 and up, that portal still has not yet launched. On Friday, Harris told reporters the portal should be up in “the next few days.”

As thousands of Alabamians started searching for a shot, appointments were hard to find. Local health departments soon ran out of doses, and Alabama did not know when it would get more.

And then the finger pointing started.

Data confusion

In its final days, the outgoing Trump Administration announced that, going forward, states would be allocated vaccine supply based on performance. Those who gave out vaccines faster would be rewarded with more doses.

In Alabama, four Republican state senators, some who had COVID themselves, including one who survived on a ventilator, published a letter blaming the state health department. They argued the department was not reporting clearly on vaccine use, making Alabama look worse than it was and costing the state future doses.

“The distribution of vaccines to Alabama will continue to be interrupted until Alabama plays by the rules,” the letter argued. “The rule is simple: The CDC will not authorize shipments to Alabama until they know we are using what we have on hand. Our citizens are paying a deadly price.”

According to the state health department, doses are still being given to states based on population, not usage. Harris on Friday said the health department has never received any official word from CDC indicating allocations would be based on performance.

And the department countered that data placing Alabama at the bottom of states for vaccine distribution is wrong.

“We know that we’re giving a lot more shots than we’re being given credit for. That’s a problem for us and for CDC,” Harris said on Friday. “We recognize that, and our staff talks to them all day long every day.”

The department has said the data issue lies with the state’s overwhelmed providers who have not consistently updated Alabama’s vaccine database, called ImmPRINT.

Some providers were “not providing complete information,” ADPH Assistant General Counsel Dana Billingsley told AL.com on Wednesday.

“This problem is being addressed and corrected in order to ensure that all doses of vaccine are counted in CDC data.”

Alabama took a heavy-handed approach toward facilities that provide the vaccine saying in a press release that it would take back vaccine doses from clinics or pharmacies that are too slow to administer it.

“ADPH will begin removing vaccine supplies from providers who are not administering vaccine in a timely way.”

But the Alabama Hospital Association told AL.com on Wednesday that the problem lies with the health department’s own software, and that providers across the state are updating their vaccination data in a timely way.

“All of our hospitals said they were reporting into ImmPRINT. From a hospital perspective, it was not an issue of entering data,” said Williamson. “The real problem the hospitals are seeing is a lack of vaccine.”

Lack of supply

Alabama continues to appear at the bottom of the CDC statistics on vaccination rates. However, Alabama edged past two other states late Friday. According to the CDC, 3.6 percent of Alabama’s population had received at least one dose. Nevada was at 3.4 percent, and Missouri was also at 3.6 percent.

Alabama remains dead last in total doses administered per capita, according to the CDC, with just 4,069 doses given per 100,000 residents. That’s because both Missouri and Nevada have given out more second doses per capita. However, the Alabama Department of Public Health also released new figures on Friday showing the state gathering speed in its efforts, reporting its best week yet, with nearly 75,000 vaccinations.

So far Alabama has administered 249,000 doses, about half of what it received, and a small fraction of what’s needed in a state of nearly 5 million people. But health officials late this week said that the biggest problem right now is lack of supply.

There are approximately 700,000 people in Alabama who are now eligible for the vaccine, Harris said on Friday.

There are currently more than 800 locations in Alabama that have signed up to give the vaccine, but the state doesn’t have enough doses to give them. Alabama receives only 50,000-60,000 first doses per week, Harris said.

“We don’t know what we’re getting either until the day before we get it, or at least until the day before it starts being shipped to us,” Harris said. “That’s very frustrating for people that are trying to run clinics, you know, it’s hard to make an appointment when you don’t know if you’re going to get vaccine or not.”

Rural Alabama

Vaccine hesitancy remains a concern. In polling earlier this year, roughly half of Americans said they would accept a vaccine. Those numbers have slowly increased to about 60 percent as of last month.

In Alabama, the fraught history of the Tuskegee study, where researchers knowingly failed to treat African Americans with syphilis in the 1950′s, continues to fuel mistrust in minority communities.

In a set of UAB focus groups with Blacks and Latinos in Alabama, only 1 in 6 said they would take a vaccine.

Black Belt community organizer Perman Hardy has lost more than 10 family members to COVID-19. Still, her relatives in rural Lowndes County are on the fence about getting the shot.

“I’m not going to tell you they’re not scared,” she told AL.com in December, pointing to a lot of uncertainty and disinformation. “You got top authorities talking about this and that. A lot of people don’t have access to a lot of information as is, and you done scared them to death.”

Alabama Arise Policy Director Jim Carnes sees an opportunity for health officials to rebuild trust with Alabamians wary of the vaccine. He said he and other community groups are awaiting leadership from ADPH on creating the public education partnerships that were discussed in planning phases of the rollout. It’s been slow, he said.

“Time is a question of life and death here,” said Carnes. “We have hundreds of deaths occurring every day, and hundreds of hospitalizations, so the sooner we can deliver the vaccine effectively to the most vulnerable groups, the more quickly we can bend that curve on mortality and hospitalization.”

Cautious optimism

To some, Alabama has been unfairly portrayed.

“I give (ADPH) a tremendous amount of credit,” said Ryan Kelly, head of the state’s Rural Health Association. “Given the fast turnaround, the second-by-second changes that are having to take place. This is faster than I’ve ever seen them work, and they’re doing really well at it.”

And there are reasons to be optimistic about the next phases of the rollout.

The state plans to launch an online signup soon. More facilities are prepared to give out more vaccines in most parts of Alabama. A new vaccine, one requiring only one injection, is expected soon. And with a new administration, more vaccines may be on the way. President Biden promised 100 million more vaccines within his first 100 days.

But as Alabama moves away from the original CDC framework, the question remains, will the most vulnerable Alabamians now be left to fight for their space in line? Carnes at Alabama Arise said that is a worry as the process becomes more of a “free for all.”

“We run the high risk of letting folks who have connections and inside information get ahead,” he said, adding that he is worried about people with disabilities and those in rural areas without good transportation or means of communication.

In December, former Alabama Gov. Robert Bentley, a practicing dermatologist, drew ire after getting a vaccine ahead of frontline healthcare workers.

And there have been more flagrant instances, as Mobile saw people who weren’t eligible manage to line up and get vaccinated at a cruise terminal. “They were taking advantage of the situation,” said Mark Bryant, spokesman with the Mobile County Health Department. “It was supposed to be by invitation only the other day.”

With local control, eligibility can still be confusing. Some counties started vaccinating the elderly earlier than the rest of the state. Two counties, Marion and Tallapoosa, went ahead and vaccinated teachers.

While the state looks ahead to building trust around vaccines, it is still struggling to communicate with an expectant public about vaccinating its population of 75 and older.

Crocker, who was turned away at the Daphne clinic, said she is disheartened by the contradictory instructions she received.

“It’s another screw-up by the government,” she said. “(President Trump) told (us) to get the shot. He wants to save our lives. (COVID) kills people. People are dying. To be turned away, because the proper information was not given out, is discouraging and frustrating.”

AL.com’s Dennis Pillion, Amy Yurkanin and John Sharp contributed to reporting for this story