Shortly after the Shelby County Health Department reported last Friday that it had tossed more than 1,315 doses of expired vaccine, the state dispatched the Governor’s Unified Command Group to look into what happened.

1,315 doses had to be tossed in inventory error

According to Tennessee Department of Health, the group is offering support, reviewing handling procedures and assessing the local Health Department’s inventory of vaccine.

The state Department of Health is expected to release more information at 2 p.m. Tuesday, Feb. 23, in a briefing led by state Health Commissioner Lisa Piercey.

The doses were thrown away on or about Friday, Feb. 12, a day or so after ice accumulation early Thursday, Feb. 11, closed many offices, including the Health Department.

Shelby County Health Department director Alisa Haushalter told reporters Friday, Feb. 19, that she was advised by the department’s pharmacist on Friday, Feb. 12, that “there was vaccine prepared to expire.”

Had the Health Department known doses were ready to expire, she said, “we would have done everything we could to get those out.”

The Health Department, Haushalter said, moved quickly to dispense 2,000 additional doses by rapidly scheduling indoor vaccination sites, which operated during the winter storms, running Monday and Tuesday.

The state’s role is to make sure the issue does not happen again, said Dr. Jon McCullers, chief pediatrician at LeBonheur Children’s Hospital and senior executive associate dean of clinical affairs and chief operating officer at University of Tennessee Health Science Center.

“When you have problems like this, you always look for the engineering solution. We talk about systems engineering, where it is not the fault of the person who made the mistake, it’s the fault of the system that allowed that person to make a mistake,” he said.

“When you reach the stage where we had to throw out vaccine, it’s time to go back to the root cause analysis and figure out how not have it happen again,” McCullers said.

The doses were made by Pfizer. Its vaccine must be thawed and diluted with saline. Once thawed, it must be reconstituted and used within five days. 

Once the vial is punctured, the vaccine is viable for six hours.

If the doses were prepared and not used, “that is really mismanagement,” said Dr. Rebecca Wurtz, associate professor in the School of Public Health at the University of Minnesota.

“If it was power going out and people scrambling because they could not get the right level of refrigeration, that is an act of God,” she said.

Haushalter did not say refrigeration was an issue.

She said the Department of Health contracts pharmacy support through Regional One Health. That support, she said, includes managing the vaccine inventory.

Dr. Reginald Coopwood, president and CEO at Regional One, quickly refuted her statement on Friday, saying the Health Department has contracted pharmacy support from the hospital for more than two decades. He emphasized that the pharmacist “works under the sole direction of the Health Department.”

“Regional One Health has no involvement in the Shelby County Health Department’s pharmacy operations, including the chain of custody of its COVID and other vaccines,” Coopwood said.

Haushalter did not comment further.

It is somewhat common, Wurtz said, that 8-10 doses may be forfeited at the end of a day or shift “because the doses were ready to go without arms to put them in. But more commonly, people have scrambled and found those arms.”

She has not heard of a “wholesale mess-up of this magnitude” with wasted doses elsewhere in the nation, although she says it’s possible others have found ways to cover up the errors.

“Obviously, the actual scenario of the story will come out, but wasting that many doses is really sad,” Wurtz said. 

“I am sure there will be some finger-pointing, but hopefully they will recognize what the system problem was and fix that and not have it happen again.”

The problem, she and others said, is indicative of a vaccine process that is remarkably complicated with almost no centralization or chain of command.

“In an emergency situation in public health, there has to be one person in charge and that person or entity has to have complete control,” Wurtz said. “When you are trying to negotiate between a contract pharmacy, multiple health departments and multiple health care organizations, it’s a recipe for disaster.” 

Friday, Haushalter said one of the fixes would be inventorying doses in smaller quantities.

Almost daily, Dr. Scott Morris says Church Health Center, which he founded, finds itself having vaccine ready to administer but no takers, sometimes because people did not keep their appointments.

“Last week, in the ice storm, we were in a similar situation. We ended up reaching out to the maintenance workers here at Crosstown (Concourse),” Morris said.

“What were we going to do if we didn’t use them? So, for me, this is all completely understandable. We don’t need to be chastising anybody,” Morris said. “The logistics of this is truly a nightmare. I know nothing about what happened with the doses going to waste. And hindsight is everything. Do I believe it could have been done better? Almost certainly.

“But, when you factor in the ice and everything else going on, we need to just move on because we are in this for the long haul. Yes, we need to keep working at this every day to fully come up with a process that we’re all going to be pleased with, but we don’t need to be taking anyone to the woodshed over this. We’re going to get it right. Our entire city is focused on getting it right,” he said. 

“I am going to be the last person to judge someone by saying this was incompetence.”

McCullers doubts anyone will be punished for the wasted vaccine.

“Unless it was intentional, and there are few cases where it was intentional,” McCullers said.