‘No waste. That’s our daily challenge’

Celsius and Fahrenheit are Kevin Smith’s steadfast companions when ushering the COVID-19 vaccines from the University of Vermont Medical Center’s loading docks to the COVID-19 vaccine clinic at the Champlain Valley Expo in Essex.

The process begins on Thursday evenings, when Smith, the Pharmacy Operations Manager at UVM Medical Center, receives an email from the Vermont Department of Health detailing how many doses of vaccine the hospital can expect the following week, and what type. The list is split by dose (first or second) and where it’s coming from (the vaccine manufacturer or Vermont Department of Health).

In this case, the vaccine arrives from Pfizer. The timer starts ticking right away: Smith and his team quickly unpack it, move it to a special freezer, verify that the shipping container maintained the appropriate temperature during transport, and log in the inventory.

“I’m mostly behind-the-scenes,” Smith says, “but, like the rest of our pharmacy team, I’m thrilled to be able to use my expertise for this effort.”

Part of that expertise is knowing how critical it is to keep the vaccine at the right temperature: The Pfizer vaccine must be kept between minus 112 degrees Fahrenheit and minus 76 degrees Fahrenheit for long-term storage. Fortunately, it doesn’t need to be kept nearly as cold for the short trip to the Expo.

There, the painstaking process of compounding – or creating the vaccine mixture – begins, a process dictated by temperature and time. Different vaccines require different temperature limits to remain effective, and the clock starts ticking the second a vial is opened; if they aren’t used within a given amount of time, they aren’t effective.

The trick is to prepare vaccine doses in advance of patient arrival, but not too far in advance, explains Michele Corriveau, the UVM Medical Center Pharmacy Oncology Manager. The number of appointments each day must be closely calibrated with the time it takes a pharmacist to prepare each dose.

“We figured out it takes one minute per dose,” says Corriveau. “That, along with the fact that we have six hours once the vial is opened before we have to get each dose in a patient’s arm.”

Modern Chemistry

The process begins when the pharmacist or pharmacy tech inverts the vial exactly 10 times to ensure that the suspension in the vial is well mixed. It’s then inspected for color and clarity, the cap removed, the stopper swabbed with an alcohol wipe, saline added and air removed. Again, the suspension is gently inverted 10 times and again inspected, an onerous process that only a chemist could love.

“No waste,” says Smith. “That’s our daily challenge.”

To help ensure that goal, each syringe is labeled: type of vaccine, volume, manufacturer’s lot number and the “beyond use” date, the time after which the vaccine can no longer be administered.

A pharmacist can compound between 8 to 10 vials per hour, so these calculations dictate the workflow each day at the vaccine clinic. One key technique to ensure that every bit of vaccine is extracted involves using a needle with a small ‘hub’ (the plastic end that attaches to the syringe tip). Needles with larger hubs tend to have ‘dead’ space, in which small volumes of vaccine can pool after the injection, potentially wasting vaccine.

On the Road Again

Promptly at 4:30 p.m., the unopened vaccine vials are transported back to the UVM Medical Center loading dock where the unopened vials are returned to refrigerators and freezers. Smith sets about the work of preparing to start all over again in 12 hours.

“To be able to help people feel like they’re going to get through this?” he says. “It’s just such a privilege.