RICHMOND, Va. — When tiny glass vials of coronavirus vaccine began rolling off production lines late last year, federal health officials set aside a big stash for nursing homes being ravaged by the virus. Health providers around the country figured as well that it was prudent to squirrel away vials to ensure that everyone who got a first dose of vaccine got a second one.
Two months later, it is clear both strategies went overboard.
Millions of doses wound up trapped in logistical limbo, either set aside for nursing homes that did not need them or stockpiled while Americans clamored in vain for their first doses. Now a national effort is underway to pry those doses loose — and, with luck, give a significant boost to the national vaccination ramp-up.
In New York, Gov. Andrew M. Cuomo has pushed the Biden administration to allow him to claw back 100,000 excess doses that were allocated to the federal program for long-term-care facilities. In Michigan, Dr. Joneigh S. Khaldun, the chief medical executive, is raiding nursing home doses that she said had been locked in a “piggy bank” controlled by CVS and Walgreens, the two pharmacy chains in charge of the federal initiative.
And in Virginia, Dr. Danny Avula, the state’s vaccine coordinator, said he has been “wheeling and dealing like on a trading floor” to free up tens of thousands of doses for the general population.
Dr. Avula, a 42-year-old pediatrician and preventive medicine physician, came to the job in early January to find multitudes of Virginians languishing on vaccination waiting lists and less than half of the state’s vaccine allotment actually making it into arms.
So first he cut off the spigot of doses for nursing homes until existing stocks were exhausted. Then, in talks with six of the state’s hospital systems, he offered a deal: If they released the vials they were saving for second doses, they would be guaranteed two doses later for every vial they surrendered.
The hospital administrators agreed, with some trepidation. “You’ve got to be sure about this,” he said they told him. “Because we can’t be left empty-handed.”
The get-tough approach in Virginia and other states has begun to pay off. The gap between the number of doses shipped to states and the number injected into arms is narrowing: More than three-fourths of the doses delivered are now being used, compared with less than half in late January, according to the Centers for Disease Control and Prevention’s data tracker.
President Biden is pressing for speedier inoculations as well — a case he is expected to make on Friday, when he travels to Kalamazoo, Mich., to visit the manufacturing plant of Pfizer, one of the two manufacturers of federally authorized vaccine.
Federal officials estimate that as many as six million vaccine doses are still being unnecessarily stowed away. Freeing them up could increase the number of doses used by more than 10 percent — significantly stepping up the pace of the nation’s inoculation program at a time when speed is of the essence to save lives, curb disease and head off more contagious variants of the virus. So far, 56 million shots have been administered, and only 12 percent of Americans have received one or more doses.
The idea that doses are sitting in cold storage while millions of people languish on waiting lists has deeply frustrated government officials. The roots of the problem are twofold.
First, when the federal vaccination program for long-term-care facilities began late last year, the C.D.C. based allotments on the number of beds, even though occupancy rates are the lowest in years. According to the American Health Care Association, a trade group, only 68 percent of nursing home beds and 78 percent of assisted living beds are now filled.
Then the C.D.C. doubled that allotment to cover staff. But while four-fifths of long-term-care residents agreed to be vaccinated in the first month of the program, 63 percent of staff members were not given shots, the agency reported. Some of them have since been vaccinated, although it is not clear exactly how many more.
Despite the lack of uptake, the pharmacy chains that administer the program continued tapping their allotments from the federal government. At one point in Virginia, Dr. Avula said, they had used fewer than one in every three doses they had on hand.
As “good, corporate, risk-averse companies,” Clark Mercer, the chief of staff to Gov. Ralph Northam of Virginia, said, “if they can draw down, they are going to draw down.”
Even more vaccine has been hoarded as second doses, federal and state officials say. Both authorized vaccines from Moderna and Pfizer-BioNTech require two doses, spaced three to four weeks apart.
The White House has been urging states not to squirrel away second doses ahead of time, and is providing three-week projections of supply as reassurance that they will not come up short.
“We believe that some health care providers are regularly holding back doses that are intended as first doses and instead keeping them in reserve for second doses,” Andy Slavitt, a White House adviser, said at the start of the month. “That does not need to happen and should not happen.”
But prying loose more second doses requires wary health care officials to have faith in a brand-new supply chain, said Dr. Marcus Plescia, the chief medical officer of the Association of State and Territorial Health Officials.
“There’s been this big push that we shouldn’t hold vaccine for second doses, we should just give it because there will be more,” he said. “But I think that’s asking a lot from vaccine providers, because their heart is in the place that they gave somebody a vaccine and they want to make sure when that person comes back for their second dose, it will be there.”
Some governors, including Mr. Cuomo, are insisting on a separate reserve for second doses.
“I am holding second doses that are for people who are scheduled for second doses,” Mr. Cuomo said in a recent interview. He added: If “I have your mother’s second dose earmarked and sitting on a shelf, I don’t consider that unused.”
In Virginia, the job of breaking through supply logjams has fallen to Dr. Avula. Mr. Northam plucked him from his job as health director for Richmond and the surrounding county on Jan. 6 to run the state’s vaccine program.
It was three weeks into the nation’s rollout, and Virginia was ranked near the bottom of states in shots delivered. Announcing Dr. Avula’s appointment, Mr. Northam warned hospitals, pharmacies and health care providers of consequences if they did not pick up the pace.
“You use it or you lose it,” he said. “I want you to empty those freezers and get shots in arms.”
Still, more than two weeks later, state data showed that Virginia was using only 45 percent of doses.
Part of the problem was faulty data. Nationally, federal officials estimate that accounts for only about 2 percent of doses that show up as unused. It was a bigger factor in Virginia.
Until a software patch was created, vaccinations of hospital staff did not show up in the state’s system. Some clinics were using paper records and were slow to file.
Dr. Avula put a 10-person team on “pounding the data,” and the state began rising in the national rankings.
Then he tackled stockpiles. Walgreens and CVS had already drawn down most of the quarter-million doses allotted to the state’s long-term-care program. On Jan. 25, with the C.D.C.’s permission, Dr. Avula put the 62,000 doses that were left under state control.
Many other states are doing the same. At least 20 states said they had shifted or planned to shift doses that had been set aside for long-term-care facilities, according to a New York Times survey of all 50 states.
“We want shots in arms as urgently as the states do,” said T.J. Crawford, a spokesman for CVS. “In some cases we’re proactively asking that they ‘reclaim’ allocation we won’t need.” He added that the excess doses in Virginia amounted to only 13 percent of what CVS had been allocated there.
To get more second doses out of cold storage, Dr. Avula and other top state officials picked six of the state’s 20-some hospital systems that had proved they could deliver first doses efficiently and reach communities.
They gave the hospital administrators an ironclad guarantee of two fresh second doses of vaccine for every stockpiled second dose they gave up — one dose to cover the person for whom the second dose was designated, and one to cover the person who got the freed-up dose. Scrawling on a huge whiteboard with green and blue markers, Dr. Avula kept track of the state’s promises for the weeks ahead.
By the end of the week, the state had sprung loose enough shots out of the second-dose reserves to at least partially protect 40,000 more Virginians.
Riverside Health, a network of five hospitals, was one of the companies that cooperated. Dr. Mike Dacey, the firm’s president, said he wanted the hospitals’ freezers to be empty of vaccine by the end of each week. As of last Monday, Riverside had administered 37,000 first doses and 11,000 second doses.
“It is a matter of trusting” that the state will provide enough second doses from week to week, Dr. Dacey said.
Virginia is now using its first doses nearly as fast as it gets them, with 98 percent administered. But a substantial backlog of roughly 244,000 doses remains while 1.2 million Virginians remain on waiting lists.
Dr. Avula said that cache of doses should be reduced by more than one-third — an effort he said required “leaning on and cajoling” other health providers and could take several weeks. Mr. Northam said in an interview that he wanted doses used within three or four days of arrival.
A flood of public requests for data gave the state a chance to create a new incentive not to hoard.
On Wednesday, Virginia updated its official website to show precisely how much vaccine had been delivered to more than 240 of the state’s health care providers — and how much had been used.
“This kind of visibility does, you know, motivate,” Dr. Avula said.
Reporting was contributed by Danielle Ivory, Alex Lemonides, Jordan Allen, Benjamin Guggenheim, Barbara Harvey and Kristine White. Kitty Bennett contributed research.