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Rural states got off to a faster start on vaccinations, but big urban centers expected to gain momentum

CDC lists Massachusetts in the middle of the pack, along with Texas and New York.

Physician Alister Martin received one of the first doses of the Pfizer-BioNTech coronavirus vaccine at Massachusetts General Hospital in Boston on Dec. 16.
Physician Alister Martin received one of the first doses of the Pfizer-BioNTech coronavirus vaccine at Massachusetts General Hospital in Boston on Dec. 16.Craig F. Walker/Globe Staff

West Virginia deployed National Guard units to get first doses of the vaccine to every nursing home before New Year’s Day. In South Dakota, the Civil Air Patrol waited at the Sioux Falls airport to ferry vaccines to remote parts of the state.

And a small hospital in Nebraska’s corn and soybean belt mixed logistics with a can-do attitude to vaccinate front-line staffers hours after its precious shipment arrived.

“We’re getting it out there as quickly as we receive it,” said Daniel Bucheli, a spokesman for the South Dakota Department of Health. “Shots in arms — that’s the goal.”

While the national COVID-19 vaccination rollout has been shaky almost everywhere, the states most nimble in getting larger swaths of their residents immunized in the early weeks have been rural with small populations, not health care hubs like Massachusetts, New York, or Texas.

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Data from the Centers for Disease Control and Prevention, posted Friday evening, show West Virginia leading the pack in per-capita vaccinations, with 4,867 doses per 100,000 people, followed by South Dakota, North Dakota, Vermont, and Nebraska.

Massachusetts, which had given 2,197 doses per 100,000 people by Friday, ranked near the middle of the pack, behind all the other New England states. But Massachusetts was on a par with New York and Texas, and ahead of Pennsylvania and New Jersey, based on doses per 100,000.

With the US government ceding vaccination programs to the states, offering no central plan with goals or best practices, each state has scrambled to set priorities — sometimes, but not always, adopting CDC recommendations — while searching for sites and trained staff to administer shots.

“It’s like someone dropped the box in front of your home and said it’s up to you to assemble the furniture,” said Sridhar Tayur, professor of operations management at Carnegie Mellon University’s Tepper School of Business.

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More densely populated states with fragmented health systems and overstretched public health agencies so far have been slower to set up infrastructure and remove bottlenecks, said analysts who are tracking the vaccine launch.

“If you have a very large population, it’s harder to reach all corners,” said Josh Michaud, associate director for global health policy at the Henry J. Kaiser Family Foundation.

Massachusetts stumbled at the outset of its rollout, when some hospital workers were temporarily prevented from scheduling vaccine appointments because of a computer glitch and there were scattered reports of employees cutting in line. But its vaccination program has expanded in the past two weeks to senior care sites, and late last week started providing shots to first responders such as police and firefighters.

Baker administration officials defended the pace of the vaccine roll-out, saying it was “in line with the original time frame.” Other New England states have less complex vaccine plans and several started vaccinations at long-term care facilities a week earlier than Massachusetts, officials said.

Although the state’s vaccination rate per 100,000 population is somewhat lower than in other New England states, Baker officials noted, the total number Massachusetts had administered by Friday — 151,430 — is substantially greater. (In contrast Vermont administered 22,331.)

“The Massachusetts plan hinges in large part on federal cooperation as well as recipients’ willingness to receive the dose,” said Kate Reilly, spokeswoman for the state’s COVID-19 Response Command Center.

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Supply chain experts caution against putting too much stock in the early data, arguing the rankings will change as vaccination programs ramp up in the coming weeks.

Rather than attempt a reset of distribution plans, John Carrier, a systems dynamics specialist at MIT’s Sloan School of Management, said the states that will be most successful in vaccine distribution will embrace “continuous improvement,” finding all the pieces of their systems that are broken and fixing them.

But the scale of the effort — immunizing between 70 percent and 90 percent of the 330 million Americans — is unprecedented and all states are facing some unique challenges.

The need to provide two doses to achieve full immunity, the differences among states in who goes first, and the challenge of obtaining informed consent from patients suffering from dementia or otherwise unable to speak for themselves have added layers of complexity.

On top of that, the vaccine made by Pfizer and BioNTech requires ultra-cold storage capacity that few public health departments or community health centers have. It’s packaged and shipped in 975-dose trays that must be divided up for smaller settings.

Across the country, including in Massachusetts, some health care workers spooked by Internet-fueled vaccine resistance have refused to roll up their sleeves, leaving hospitals or nursing homes with unwanted extra vaccine doses — and still-vulnerable staffers.

“The biggest challenge has been overcoming the misinformation about the vaccine,” said Dr. David Gifford, chief medical officer at the American Health Care Association and National Center for Assisted Living.

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Another challenge is a CDC requirement that people be watched for side-effects for 15 minutes after vaccination, and a half hour for those prone to severe allergic reactions. That means larger spaces are needed so people can be spaced six feet apart in accordance with pandemic social distancing protocols.

Some states, such as Rhode Island, have benefited from a long-established state-run vaccination program, as well as lessons learned during the 2009 H1N1 flu pandemic. By Friday evening, Rhode Island had administered 2,857 doses per 100,000 residents but trailed neighboring Connecticut, which had given 3,261 doses per 100,000.

“We’re just really trying to pile onto those things that we’ve been able to utilize successfully during other vaccination campaigns,” said Alysia Mihalakas, chief of emergency preparedness for the Rhode Island health department.

Other states are drawing on procedures used for battling influenza. “We used the flu vaccine campaign as the dry run,” said Dr. Thomas Balcezak, chief medical officer at Yale New Haven Hospital in Connecticut.

Some rural states have proved the most innovative, even while facing the formidable challenge of distributing vaccine to populations dispersed across large geographic areas.

“We felt the vaccines had to get out to these rural hospitals and health clinics because they were already understaffed,” said Alan Morgan, chief executive of the National Rural Health Association. “They’re getting slammed by the virus and can’t afford to have their clinical staff get infected.”

Nebraska set up a network of transfer stations to ship vaccines quickly to rural farming areas that lack cold storage freezers. The urgency stemmed from a need to get health workers and others inoculated before vials spoiled.

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“We received the vaccine by noon, and by two it was in arms,” said Marty Fattig, chief executive of the 16-bed Nemaha County Hospital, which received 200 of the 975 doses that were sent to southeastern Nebraska. “There’s just a lot less red tape in a rural area than in a place like Boston. We can adjust what we do at a moment’s notice.”

Fattig said his hospital staggered vaccinations, with half his front-line staff getting their first doses the day the shipment arrived, and half two days later. “We had a plan in place, and people were ready,” he said. “We knew we had to get it into arms before it went bad, and we took that seriously.”

Myrtle Thompson received a shot of the COVID-19 vaccine from Wayne County Health Department Administrator and Director of Nursing Tracey Sebastian, as the health department offers COVID-19 vaccines for anyone 80 years of age or older at a drive-thru site on  Dec. 31 in Wayne, W.Va.
Myrtle Thompson received a shot of the COVID-19 vaccine from Wayne County Health Department Administrator and Director of Nursing Tracey Sebastian, as the health department offers COVID-19 vaccines for anyone 80 years of age or older at a drive-thru site on Dec. 31 in Wayne, W.Va. Sholten Singer | The Herald-Dispatch/Associated Press

West Virginia was the only state to opt out of the federal pharmacy partnership, which contracted with CVS and Walgreen’s to run vaccine clinics at long-term care facilities.

By setting up its own program that relied on the National Guard and independent local pharmacies, the state was able to complete its first round of inoculations at all 200 senior sites by Dec. 29, said Marty Wright, chief executive of the West Virginia Health Care Association.

“We got it done in about 15 days, and that included Christmas break,” Wright said. “We knew [the federal program] had a two-week activation delay, and we didn’t want to wait that long.” By matching nursing homes with about 50 local pharmacies or regional chains, he said, “it kind of took the politics and bureaucracy out of it.”


Robert Weisman can be reached at robert.weisman@globe.com. Follow him on Twitter @GlobeRobW. Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter @felicejfreyer. Dasia Moore can be reached at dasia.moore@globe.com. Follow her on Twitter @daijmoore.