In late January, Isabela Medina sat on the floor at the back of a grocery store for about five hours. She was waiting there in the hopes of receiving a “leftover” COVID-19 vaccine — a dose from an open vial that would expire and be thrown out at the end of the day if it wasn’t injected into an arm. The 25-year-old was in luck: A health care worker announced there were eight leftover doses. They shouted out into the grocery aisles in a booming voice: Anyone here over 65 want a vaccine? Then, they turned to Medina and the other so-called “vaccine hunters” in line alongside her. Soon, she was on her way home, triumphant and somewhat relieved with a vaccine card in-hand.
But Medina’s comfort at receiving the vaccination was tinged with something else. “I felt a sense of guilt, and was really aware of my privilege in that moment,” she says, now. “But the more of us [who] get vaccinated, the more we help everyone around us be safe.” With that in mind, Medina posted about her experience on TikTok, offering tips on how to “vaccine hunt” as ethically as possible. She also criticized the vaccine distribution system. Reports of unused vaccines landing in the trash at the end of the day have made folks seeking out extra shots — often young, healthy people with job flexibility like Medina and nearly a dozen others Refinery29 has interviewed — feel justified in their pursuit of a vaccine that is still mostly only available to the elderly and those with underlying health issues.
“The system allowed for vaccines to be thrown out,” she says. “So individuals took things into their own hands.”
What should happen to “leftover” vaccines like the one Medina received has been a hot topic of debate in public health circles. “Vaccine wastage” is the result of how vaccine vials are prepared for use at the end of the day, explains Tom Kenyon, MD, Chief Health Officer at Project HOPE and former director of the U.S. Centers for Disease Control and Prevention's Center for Global Health. Each vial of the Pfizer vaccine contains up to six doses, and is stored at -112ºF to -76ºF. To prepare one dose, the entire vial must be thawed and mixed with a saline solution. After that, the remaining doses must be used within six hours or they’ll expire. The Moderna vials contain up to 11 doses. To extract one dose, the vial’s rubber cap is punctured; then, like with Pfizer, you have six hours to use the rest. The gist: These things are ticking timebombs, only instead of exploding, they fizzle out and die.
Health care workers at vaccine centers are mindful to only dethaw or puncture as many vials as they need that day, but missed appointments and miscalculations mean that every day, there are doses that are either tossed in the garbage — or given out, sometimes to people who are on the Phase 1A, 1B, and 1C priority lists, but also to young, healthy people who are in the right place at the right time. This can cause frustration, confusion, and even risky behavior. The more people flock to vaccine centers, the more risk of exposure to COVID-19. And, the more perceived issues with the vaccine rollout, the less public trust in the system.
While the Centers for Disease Control and Prevention has suggested a “flexible approach” to distributing vaccines if they’re in jeopardy of going to waste, the agency has stopped short of issuing specific best practice guidelines for how to handle leftovers. (The CDC has not returned Refinery29’s request for further comment.) As a result, states, counties and pharmacies are fending for themselves, implementing different systems in a way that can seem inconsistent and disorganized to onlookers. The number of “leftovers” given out at the end of the day also aren’t being tracked, and the officials Refinery29 spoke to said they include any leftovers given out in their total vaccines administered for each day when reporting. Wastage is tracked, sometimes more transparently than others. After a public records request by the Boston Herald, it was revealed 1,313 vaccines were wasted in the state as of the week of February 10.
Former Surgeon General Jerome Adams, MD, tweeted that it’s better to give the vaccine to someone who isn’t in a priority group — a cohort typically made up of essential workers, the elderly, or immunocompromised people — than to waste it. But some doctors have been punished, and even threatened, for giving out leftover doses to nearby people. New York Gov. Andrew Cuomo originally planned to fine health care providers $1 million and seize their medical licenses for vaccinating ineligible people. After vials were tossed in dumpsters due to these rules, they were amended.
In general, what happens to leftovers is left largely in the hands of states, counties, and pharmacy chains. Some systems are more organized than others. Giant Food, an East Coast grocery chain, first offers extras to in-store pharmacists and associates. Then they ask anyone 65 or over in the store if they can and would like to receive the vaccine. Then they move onto younger shoppers and vaccine hunters. “The idea is to not let any of the vaccine go to waste,” a Giant Food spokesperson tells Refinery29. “However we do not want people waiting in lines hoping to get extra doses and we are not having waitlists.”
It’s not a perfect system, but it is a start. And some places, like Siloam Health, a low-income health network in Nashville, TN, do have waitlist systems, through which workers call people who are eligible when there are leftover shots; another hopeful sign that fewer and fewer doses are going to waste.
Meanwhile, in Seminole County in Florida, emergency management staffers make calls to about 100 nursing homes in the area twice a week to see if they still have people who need to be vaccinated. “Right now we have a list of about 42 individuals,” says Alan Harris, Seminole County’s emergency manager. When there are leftover doses — some days there are none, other days a handful — they transport the vials in a refrigerated vehicle to the care facilities.
In Cincinnati, the city health department created an extremely organized chart system for taking vials out of the fridge, and they haven’t had any leftovers at all since the beginning of the vaccine rollout, says Virginia "Jenny" Scott, RN, the Cincinnati Health Department’s director of nursing, quality, and compliance, whose background in quality improvement made her well-suited to organize the rollout in the city. “We had one evening at the very beginning of the rollout when we were working until 9 at night trying to find arms for 15 extra vaccines,” she says. “That never happened again.” She tweaked and retweaked the system, and soon, they were down to five leftovers a night, then one — and for the last month, they’ve had none at all.
But not all vaccination sites are as discerning. Paul* tells Refinery29 about a “leftovers line” that formed outside of a mass vaccine center at Rowan College South Jersey was first come, first serve. “A girl was standing in front of me, and her mom was a few places behind me, and they switched places once we got towards the front of the line,” he said. “It’d be nice if older people got to go first, but I don’t think anyone in that line was willing to sacrifice their place if it wasn’t for family.”
“Very rarely do we have extra vaccine at the end of the night due to the work and preparation we put into planning for the day ahead,” Robert M. Damminger, Commissioner Director of Gloucester County said in a statement about the Rowan College site. “There are individuals who continue to walk-up to the site in the hopes that, when we have extras, we can inoculate them. There have been circumstances in the past where we were able to take walk-ups because of individuals not showing to their appointments or last-minute cancellations... We have never and will never throw vaccines away at the end of the day.”
Damminger adds that their system has improved with time, and, after switching to using syringes with a more “accurate draw,” they can be more precise with dosing and thus have fewer leftovers. But although individual systems are doing their best to improve, despite some kinks, the lack of clarity and consistency around the best practices for what to do with leftovers has led to serious consequences.
In Texas, Hasan Gokal, MD, was fired and is facing a grand jury indictment for allegedly stealing 10 vaccine doses. The so-called “theft” happened on December 29, during his first day supervising vaccinations at a site in a Houston suburb. In order to vaccinate the person with the last appointment of the day, at 6:45 p.m., a nurse on Dr. Gokal’s team had to puncture a new Moderna vial, meaning there were 10 doses that would expire at about 12:45 a.m. Dr. Gokal says the state health department told him not to let any doses go to waste, so he offered the leftovers to the workers and police officers on site. Most declined or had already had the shot, so, after getting permission from a supervisor, he took the vaccine home and continued calling around to find eligible candidates. He ultimately gave out nine vaccines to older, at-risk, and immunocompromised acquaintances and strangers that night, making “house-calls” and asking some to meet him at his home. When the person set to receive the last extra dose was a no-show around midnight, he gave it to his wife, who has a pulmonary disease. He filed all the requisite vaccination paperwork the next day.
Although he says public health officials had approved his actions, Dr. Gokal was fired and told he violated protocol (though in a subsequent discovery request by Dr. Gokal’s defense counsel, Harris County Public Health confirmed no protocols existed at the time, Dr. Gokal’s legal team tells Refinery29).
Someone in the HR department at Harris County Public Health added that there was a lack of “equity” among those Dr. Gokal. gave shots to that night; he says. “I know what ‘equity’ means in public health terms,” he tells Refinery29. “I asked, ‘Are you suggesting there are too many Indian names on the list?’ That was shocking to me.” The Harris County Public Health Department said they couldn’t comment on the matter due to an ongoing investigation. The Harris County DA has not responded to Refinery29's request for comment.
Many health experts believe vaccine providers should be doing more to prioritize at-risk people when it comes to distributing leftover vaccines.“We don’t want to leave out the most vulnerable people, which we tend to do all the time in this country,” says Denise Dudzinski, PhD, the professor and chair of the Department of Bioethics & Humanities at the University of Washington School of Medicine. “Vaccine centers have an obligation to vaccinate people who are at the highest risk for death and serious illness, while attending to equity issues and remembering that minority populations are at higher risk.”
Getting federal guidance on best practices for handling leftovers could be beneficial in helping ensure leftover vaccines get to the people who are most in need of them, says Jesse L. Goodman, MD, MPH, professor of medicine and infectious diseases at Georgetown University and former chief scientist at the Food and Drug Administration. “Examples of best practices shared across states in the country might be helpful,” he says.
Others disagree. “A statement from the feds might be helpful, but I don’t think there’s any necessity for federal guidelines because you’re not there on the ground,” says Norman Baylor, PhD, president and CEO of Biologics Consulting and the former director at the office of vaccines research and review within the FDA. “These decisions should be left to the local government.”
Regardless of where it comes from, there’s a need for more detailed protocols and discourse around how to best deal with leftover vaccines, in order to build public trust and ensure equitable distribution across the country. As Medina noted, when people feel they can’t trust the system, they try to fix it themselves. And when that occurs, so do disparities.
I'm in this vaccine hunter Facebook group in Minnesota to help my mom find an appointment, and everyone is just so nice and helpful, but it's incredibly fucked up that this is something we have to do.— Arie Knutson (@arielknutson) February 23, 2021
“I want to discourage individuals from ‘taking things into their own hands’, as this contributes to inequity,” Dudzinski says. “It doesn’t solve it. Everyone wants a vaccine as soon as possible, but the allocation systems, for the most part, are trying to vaccinate those who are more likely to be hospitalized or die if they get COVID. Everyone else has a moral obligation to wait their turn.”
Why I “hunt”
Brad Johnson, a public health and medical student at Tulane University, created a Facebook group in New Orleans to help people scout leftovers called “NOLA vaccine hunters.” The group has since expanded into a network spread across the country. “Any arm is better than the trash,” he says, calling the country’s vaccine rollout a “patchwork of chaos.” He feels that he’s “filling in a gap the government left in the system.”
Although many vaccine hunters have a list of justifications for their actions — the main being that they’re ensuring no shots go to waste — their motivations are personal, too. Many cite anxiety as a driving force.
Medina described worrying about getting COVID-19 and giving it to her parents, with whom she’d been staying temporarily. As a Latina and first-generation immigrant, she also wanted to get it to show her parents and her community that the vaccines are safe.
Generally, getting the shot assuaged some of Medina’s anxieties about the pandemic — though it also prompted new ones. “I feel badly that the system didn’t create a place where those vaccines could have gone into tier one arms,” she says.
Although Medina got some support from commenters after posting about getting the vaccine on TikTok, she also took a lot of heat for advertising that she got the shot. But she doesn’t think she’s the one who should be critiqued. “Half the people in line with me were my age, too,” she says. “This system allows for this. And there’s a part of me that says, ‘You can’t blame us for trying.’ Unless the government starts to enforce guidance on this — which I think should happen — people are going to keep doing it.”
“We’re not gaming the system, we’re just trying to do our best in a failed system,” she says.
But Scott, who has worked so hard to fine-tune Cincinnati’s vaccination distribution plan in real time in order to eliminate vaccine waste, says that people have been calling the system “failed” and “disastrous” too soon. She emphasizes that she and her team and others like them across the country are working hard to ensure there are no leftovers — and if there are, that they’re distributed fairly. “People need to hear that there are people handling this process with precision,” she says.
And the truth is, eventually anyone will be able to get a vaccine and it won’t matter who leftovers go to in the same way. Efforts to get shots into arms are happening more quickly than before. Providers are administering close to 1.61 million doses per day now, and Anthony Fauci, MD, director of the National Institutes of Allergy and Infectious Diseases, predicted earlier this month that it’ll be “open season” for vaccinations by April. The leftovers are a problem that’s already impacted people like Dr. Gokal, and, on a smaller scale, like Medina. But for federal agencies and vaccine centers, it may be further down on their list of worries. The pandemic is not over, after all.
“What matters most is that people know the vaccine is trustworthy and that they get it,” Dr. Gokal says. “Despite everything, if I can do even a little bit to push the bar towards herd immunity, I’ll do it. Those 10 doses I gave mattered. Every dose matters.”
*Paul's name has been changed.