Vaccine vials to be administered at the FEMA-supported mass vaccination at the Four Seasons Town Centre in Greensboro. Clare Grant / Carolina Public Press.

When the COVID-19 vaccines entered the last stages of development, North Carolina officials submitted a vaccine plan to the U.S. Centers for Disease Control and Prevention outlining their intention to give the first available doses to a population hit hard by the pandemic: health care workers with in-person patient contact.

The plan estimated this top-priority group would be about 102,000 to 117,000 individuals who would choose to be vaccinated, and an additional 180,000 to 220,000 non-frontline health care workers would be vaccinated.

But data obtained from the state Department of Health and Human Services shows that, as of Feb. 24, more than 930,000 North Carolinians received first doses of COVID-19 vaccines as part of Group 1, nearly triple even the highest original estimates of first doses needed for state’s health care workers, raising questions about who received vaccinations under the state’s top-priority group and whether they were properly screened. 

The original plan cited Bureau of Labor Statistics data showing roughly 450,000 health care workers in the state, just less than half of the number of first doses administered to Group 1 recipients.

“The way we define it, it’s hard to find a data source out there that can actually give us accurate estimates of the number of people in the group,” said Dr. Charlene Wong, Chief Health Policy Officer for COVID-19 at the NC Department of Health and Human Services (DHHS), during a phone interview with Carolina Public Press on Friday.

State officials stopped tracking which group an individual claims in order to be eligible for the vaccine, allowing providers to enter the information “if known.”

“Per their agreement with the state, providers are responsible for confirming that people are eligible to receive a vaccine,” DHHS spokesperson Chris Mackey wrote, but as of March 5, providers are only required to group for eligibility into CVMS, the state’s vaccination management system, “if known” under DHHS guidance.

Data from DHHS shows 931,451 first doses were administered to individuals identifying as members of Group 1 through Feb. 24, but “DHHS does not have exact data on the total number of people vaccinated in Group 1 and Group 2,” Mackey said.

“Since North Carolina began vaccinations, priority groups have been redefined, and providers have captured this data inconsistently.”

Who is a health care worker?

The original vaccine plan submitted to the CDC in fall 2020 defined the first group prioritized, then called phase 1a, as “health care workers and medical first responders who are at high risk of exposure based on work duties or who are vital to the initial COVID-19 vaccine distribution” and staff of long-term care facilities.

Under the original plan, nurses, physicians, dentists, hygienists, EMT/paramedics and home health workers who were also at high risk of exposure to the potentially deadly virus were to be the first to receive the vaccine. 

The plan defined “high risk of exposure” as “those caring for COVID-19 patients, cleaning areas where COVID-19 patients are admitted, performing procedures at high risk of aerosolization (e.g., intubation, bronchoscopy, suctioning, invasive dental procedures, invasive specimen collection, CPR), handling decedents with COVID, administering vaccine in initial closed or targeted vaccination clinics.” 

As the vaccine distribution began, Secretary of Health and Human Services Dr. Mandy Cohen reiterated the high priority of the state’s medical professionals. 

“The best way to fight COVID-19 is to start first with the vaccinations for those at highest risk, reaching more people as the vaccine supply increases,” she said at a Dec. 15 press conference. “That’s why we’re starting first with our health care workers at highest risk of exposure and our long-term care staff and residents.” 

Long-term care workers’ doses were offered through a separate system, the pharmacy partnership for long-term care program, run by CVS and Walgreens in partnership with the federal government. They are not included in the data that DHHS provided unless they opted to get a dose through a state provider rather than one of the federal partners, Mackey said.

Although state officials announced an updated plan on Dec. 30 to align with new CDC guidance, health care workers with possible COVID-19 exposure continued to be first in line, according to DHHS statements at the time.

“Hospitals and local health departments are vaccinating health care workers caring for and working directly with patients with COVID-19 and those giving vaccines,” a statement from DHHS read.

On Jan. 14, state officials announced a move to make all health care workers, regardless of exposure level, eligible as part of Group 1. 

The most recently available and self-reported data from the American Hospital Association shows that in 2018, North Carolina had 164,798 full-time hospital personnel and 40,144 part-time personnel, according to the N.C. Healthcare Association.

The 204,942 hospital employees make up some but not all of the state’s health care workers. 

Group 1 includes paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients, bodies or infectious materials,” Mackey said.

“This is a much broader category than our early planning estimates, which were based on North Carolina Bureau of Labor Statistics categories for occupation and therefore a narrower definition of health care worker.”

The original vaccine plan submitted to the CDC identified 448,940 health care workers using Bureau of Labor Statistics categories for a range of health care occupations in a variety of settings, including physicians, nurses, paramedics, lab technicians, medical assistants, nutritionists, optometrists, home health care aides and others.

The Kaiser Family Foundation found an only slightly higher estimate of 472,500 health care workers with direct patient contact in North Carolina in 2019. The figure includes “workers providing direct clinical care, such as doctors, nurses, and aides; workers providing direct patient support, such as environmental and food staff; and first-line supervisors and managers of these occupations.”

It is not expected that every health care worker in the state will elect to receive the vaccine, Wong said. Because some individuals may choose not to get the vaccine, the original plan estimated a maximum need of 337,000 first doses for health care workers.

Even if every eligible health care worker opted for the vaccine, under the original plan estimate or the Kaiser Family Foundation estimate, health care workers would account for only half of the individuals vaccinated as part of Group 1 through Feb. 24.

An individual claiming eligibility as a health care worker did not have to show evidence of their role, as all vaccine recipients are not required to show proof of age or employment.

“Individuals can self-attest to the criteria (e.g., age, job role, health status, living situation) that they qualify for in eligible priority groups,” DHHS provider guidance states.

Changes in age-based prioritization

Some of the nearly million doses administered to Group 1 before Feb. 25 may be individuals 75 and older because of changes to the way the state categorized vaccine recipients.

North Carolinians ages 75 and older were originally part of Group 1, then called phase 1b, and became eligible for vaccinations the week of Jan. 4. In that week, 33,415 individuals ages 75 and older received doses, according to the DHHS dashboard.

The following week, state officials moved individuals 75 and older into an expanded Group 2, which included individuals 65 and older. In the week of the announcement, 102,027 individuals 75 and older received the vaccine. 

It is unclear whether the 135,442 individuals 75 and older who received doses in those two weeks in January were included in Group 1 or Group 2.

Line-skipping and vaccine management protocols

While some seniors struggled to find available appointments in January and February, other individuals skipped the line, taking doses out of order in violation of the state’s suggested protocol. 

At least one major hospital system, Atrium Health, allowed individuals who did not qualify as front-line health care workers with priority to schedule vaccinations initially. 

Individuals who booked appointments by self-attesting to being members of a group for which they do not qualify could account for some of the doses beyond the original estimate administered to individuals identified as group 1. 

Asked Friday about the possibility of individuals who did not qualify as group 1 but who received the vaccine accounting for some of the difference in numbers, Mackey said, “I think that opportunity is there.”

But line-skipping may account for only part of group 1 recipients. The discrepancy could be a reporting issue because of what Wong described as “messiness” in the data.

“The data do not reflect the total number of people vaccinated in each group throughout the state because the data are inconsistent,” Mackey said.

CVMS, the multimillion-dollar, state-created software system to manage the vaccination process, required providers to enter which group an individual declared for eligibility.

In late January, the N.C. Healthcare Association issued a letter to state officials calling CVMS a “burdensome and ineffective” system that slowed the vaccination process. 

Because of the “complexities of accurately capturing the data,” DHHS changed the process to no longer require entry of an eligibility group into the CVMS, Mackey said. On March 5, the state shared with partners that the “required” field for group eligibility would be “required, if known.” 

Mackey described several reasons for the change. 

“New vaccination sites such as pharmacies are not currently able to collect these additional data elements,” Mackey said. “In addition, vaccine providers can enter recipients’ information into CVMS either by a bulk upload (e.g., a health system may bulk uploaded (sic) all of their 65+ patients) or at the point of care, and the COVID questionnaire for vaccine recipients is optional. The group information also has the option to be auto-populated.”

In directions for providers, the department acknowledges that health care providers may make the determination about whether someone is eligible or not.

 A provider “can use discretion to administer a COVID-19 vaccine to a Recipient with a ‘not eligible’ status,” the guidance states. “The HCP can determine if a Recipient falls under a currently eligible Priority Tier group and proceed with vaccination (in accordance with the CDC and NCDHHS prioritization of COVID-19 vaccine recipients).” 

Currently, members of groups 1, 2 and 3 may self-identify for vaccinations throughout the state.

North Carolina is moving to Group 4 starting March 17, Gov. Roy Cooper announced Thursday. While the state offers guidance on when to move to the next prioritized group, county-level providers independently determine when to move from one group to the next.

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Laura Lee is the former news editor at Carolina Public Press.

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