A conundrum for hospitals: How to vaccinate their sick patients against Covid-19

In my first year as a doctor, I’ve cared for many patients who eagerly wait their turn to get the Covid-19 vaccine.

It should be coming soon. This week, President Joe Biden announced he’s moving up the deadline for states to make all American adults eligible for coronavirus vaccines, shifting the date from May 1 to April 19. Prior to this, all 50 states had already expanded or announced a timeline to expand vaccine eligibility to anyone 16 or older by May 1.

Now I can’t help but wonder: Does this include my adult patients who are sick and stuck in the hospital?

I spoke with colleagues who shared my concerns. I learned that at some hospitals, even if patients are sick with something other than Covid-19, they can’t get the vaccine until they’re discharged. This means they can only get the vaccine at a clinic or offsite location — not when they’re actually a patient in the hospital.

The hospital where I work is providing the second dose of coronavirus vaccines to people who are hospitalized after their first dose. That’s not the case everywhere.

I reached out to hospitals in several parts of the country to understand where their vaccination efforts stood, and the answers varied. Some hospitals have already started rolling out vaccines to their sick patients, while others are trying to figure out how to deal with limited supplies and logistics.

The unifying challenge for each hospital system is to come up with their own plan.

“There’s nothing specifically in the CDC guidelines that says you should or you shouldn’t provide vaccine to inpatients,” said Dr. David Weber, medical director for infection prevention at the University of North Carolina Medical Center.

I contacted the US Centers for Disease Control and Prevention to ask about plans to provide hospitals with guidance on coronavirus vaccine administration to sick patients, but it has not yet responded.

For patients sick with Covid-19, the CDC recommends waiting to get the vaccine until symptoms resolve and quarantine ends.

But for patients who are sick with something other than Covid-19, hospitals are left to decide how to make vaccines available to them.

Each hospital system gets a certain number of vaccines each week from its respective state. At UNC Health Care, where Weber works, vaccines haven’t been distributed to hospitalized patients yet, partially due to supply issues.

“We never know how much [vaccine] we’re going to get until just before we get it. So the state’s pretty transparent. We know where all their vaccines are going,” he said.

“What’s not transparent at the moment is the federal government — and this is a legacy of the previous administration. So there’s no dashboard that I can go to or for that matter the state health director can go to that sort of says that the next month, ‘Here’s how many vaccines are being made by Johnson & Johnson, Pfizer, Moderna. Here’s how we’re distributing them.’ “

So far, UNC Health Care is only delivering vaccines to patients in nursing homes or those who schedule appointments at outpatient settings such as drive-thrus and doctors’ offices.

It’s not the only hospital system doing so. In Massachusetts, hospitals around the state are trying to find solutions to expand Covid-19 vaccine distribution.

Dr. Karl Laskowski, associate chief medical officer at Brigham and Women’s Hospital, and a member of the Mass General Brigham vaccine operations team, said that other than psychiatric and rehab patients who live together and fall under the CDC’s Covid-19 shared housing guidelines, “We are not currently administering first or second doses to inpatients, across the Mass General Brigham system.”

Instead, the vaccine operations team is developing a process to administer inpatient vaccines “as soon as vaccine supply allows.”

At Beth Israel Lahey Health, vaccine supply and logistics around storage and distribution of vaccine posed challenges. The hospital where I work, Beth Israel Deaconess Medical Center, is a part of Beth Israel Lahey Health.

By mid-April, the hospital system plans to expand the supply from outpatients to people across all of their hospitals who end up admitted after getting their first dose of the vaccine.

“We are actively implementing protocols to provide second doses of vaccine for patients who received their first vaccine dose in the outpatient setting, and become eligible for their second dose during an inpatient stay at one of our hospitals,” said Dr. Sharon Wright, chief infection prevention officer for Beth Israel Lahey Health.

Once vaccine supply increases, the goal for Beth Israel Lahey Health is to administer first doses across their hospitals too.

Other challenges related to inpatient vaccines include training hospital staff to use the state’s data entry system that tracks vaccine information, making sure vaccines don’t go to waste, and figuring out if a side effect a patient experiences is from the vaccine or from another illness, according to Weber from UNC Health Care.

“If you’re in the hospital and you develop a fever, we often worry that you’ve developed a severe infection, and so you get a blood culture and other evaluation. If you suddenly developed a new headache, you might get a CT scan — things that we probably don’t do for mild disease as outpatients,” he said, when referring to fever and headache as common vaccine side effects.

Scheduling two doses

In some cases, a patient may get sick and admitted to the hospital between the first and second dose of the Pfizer/BioNTech or Moderna vaccine. For hospitals that aren’t distributing inpatient vaccines, this could mean a delay in a patient getting their second dose.

The second dose of the Pfizer or Moderna vaccines can be given up to six weeks after the first dose, according to CDC guidelines. And although there is limited data on the vaccine after the six-week window, patients don’t need to start over and get their first dose again. They can get the second dose when they’re able to.

While delaying second doses isn’t ideal, even hospitals that are providing vaccines to their sick patients don’t see it as an issue.

“It is very infrequent, and the first dose of the vaccine provides decent coverage,” Michael Brownlee, chief pharmacy officer for University of Iowa Health Care, wrote in an email. “We are intermittently giving 2nd doses to inpatients when we know they won’t be able to get their 2nd dose on time in the community. For example, we’ve had psych patients that we’ve helped due to the complexity of their clinical case.”

The University of California San Francisco Medical Center has also made second dose vaccines more widely available.

“UCSF has implemented a protocol for hospitalized patients who have received a first COVID-19 vaccination prior to hospitalization and are unable to receive their second dose,” wrote Dr. Adrienne Green, chief medical officer for UCSF Medical Center, in an email.

Single-dose solution

But some patients won’t need to worry about getting a second dose at all. In San Francisco, the Department of Health has guidelines on how to provide hospitalized patients who meet the age cutoff or who are discharged to a skilled nursing facility with the Johnson & Johnson vaccine, according to Green.

The Johnson & Johnson vaccine — which only requires a single dose — has already been administered to some hospitalized patients in New York. Last month, the New York State Department of Health promoted the single-dose vaccine for patients specifically in the hospital who were ready to be discharged and met eligibility criteria.

Mount Sinai South Nassau in Oceanside, New York, started offering vaccines in early March.

“So the state did roll it out as an inpatient initiative — the entire state. So anyone who wanted it had to understand that this was specifically earmarked for an inpatient initiative. And literally it’s for patients going home in a day or two,” said Dr. Adhi Sharma, chief medical officer of Mount Sinai South Nassau.

Unlike other hospital systems, Mount Sinai South Nassau hasn’t run into supply issues, with the Johnson & Johnson vaccines being additions to the regular supply, according to Sharma.

Hospital staff only offer the vaccine to patients who meet eligibility criteria and are close to discharge, he said. Once the patient gets the vaccine, staff are able to closely monitor the patient for 15 to 30 minutes. By monitoring the patient close to discharge, the medical team is able to avoid confusion as to whether an immediate side effect is related to the vaccine or a medical condition they had while in the hospital.

Nurses are also able to document vaccine administration into the hospital’s electronic medical record that they’re already familiar with. This data in turn gets reported to the New York State immunization registry. In over a week, the hospital was able to deliver 70 doses of the Johnson & Johnson vaccine to their sick patients, according to Sharma.

“I would say 60% of people we offer it to, take it. They’re very thrilled to be offered a vaccine. They’re very happy and grateful. The remaining 40% reject the vaccine. And of that 40%, 20% reject it because they don’t want J&J because they’ve heard issues about its relative efficacy and they misinterpret that to mean it’s inferior. And the remaining 20% are people who don’t want vaccinations,” he said.

Vaccine experts agree that all three vaccines currently available in the United States provide good protection and prevent people from getting severely ill.

As more people around the country are vaccinated — including hospital patients — I’m hopeful that we’re one step closer to a new normal.

But for now, I’ll wear my mask, socially distance and encourage my patients to get any vaccine available to them.

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