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story.lead_photo.caption University of Scranton nursing student Glen Johnson administers the Moderna COVID-19 vaccine to a medical professional during a clinic at the Throop Civic Center in Throop, Pa. on Saturday, Jan. 9, 2021. The Lackawanna County Medical Society had about 400 doses of the Moderna vaccine on hand to administer to people in Pennsylvania's Phase 1A group of the vaccine rollout plan, which is limited to healthcare personnel and long-term care facility residents. (Christopher Dolan/The Times-Tribune via AP)

PROVIDENCE, R.I. (AP) — Public health officials sounded the alarm for months, complaining they did not have enough support or money to get COVID-19 vaccines quickly into arms. Now the slower-than-expected start to the largest vaccination effort in U.S. history is proving them right.

As they work to ramp up the shots, state and local public health departments across the U.S. cite a variety of obstacles, most notably a lack of leadership from the federal government. Many officials worry they are losing precious time at the height of the pandemic, and the delays could cost lives.

States lament a lack of clarity on how many doses they will receive and when. They said more resources should have been devoted to education campaigns to ease concerns among people leery of getting the shots. And although the federal government recently approved $8.7 billion for the vaccine effort, it will take time to reach places that could have used the money months ago to prepare to deliver shots more efficiently.

Such complaints have become a common refrain in a nation where public health officials have been left largely on their own to solve complex problems.

"The recurring theme is the lack of a national strategy and the attempt to pass the buck down the line, lower and lower, until the poor people at the receiving end have nobody else that they can send the buck to," said Gianfranco Pezzino, who was the public health officer in Shawnee County, Kansas, until retiring last month.

Operation Warp Speed, the federal vaccine program, had promised to distribute enough doses to immunize 20 million people in the U.S. in December. It missed that target, and as of Friday, about 6.6 million people had received their first shot, according to a tracker from the Centers for Disease Control and Prevention. About 22 million doses have been delivered to states.

The American Hospital Association has estimated 1.8 million people need to be vaccinated daily from Jan. 1 to May 31 to reach widespread immunity by the summer. The current pace is more than 1 million people per day below that.

President-elect Joe Biden on Friday called the rollout a "travesty," noting the lack of a national plan to get doses into arms and reiterating his commitment to administer 100 million shots in his first 100 days. He has not shared details and was expected to discuss the effort this week. His office announced a plan to release most doses right away, rather than holding second doses in reserve, the more conservative approach taken by the Trump administration.

The Trump administration defined its primary role as developing coronavirus vaccines and delivering them to states, which would then take over and ensure vaccine doses traveled "the last mile" into arms. Each state had to develop its own plan, including issuing guidelines for who gets vaccinated first. Several health experts complained about that approach, saying it led to confusion and a patchwork response.

"Let's just say that I was disappointed how they handled testing, and the vaccine deployment has reminded me of how disappointed I was when they handled testing," said Dr. Mysheika Roberts, health commissioner in Columbus, Ohio.

Several public health officials and experts said they believe some of the early glitches are smoothing out. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials, said the slow start should not be surprising given the immense scale of the task.

"It was not going to be seamless," he said.

Still, Plescia said the federal government could have done more ahead of the rollout — such as releasing billions of dollars earlier to help with staffing, technology and other operational needs.

An ongoing investigation by the Associated Press and Kaiser Health News detailed how state and local health departments have been underfunded for decades. Public health officials have warned since the spring that they lacked the staff, money and tools they needed to deploy a vaccine. The money was not approved until the end of December.

Vaccine distribution involves a long, complex chain of events. Every dose must be tracked. Providers need to know how much staffing they will need. Eligible people must be notified to schedule their shots, given the vaccine's handling requirements and the need to observe people for 15 minutes after the shot — all while social distancing is observed.

It's difficult to plan too far ahead because the number of doses the state receives can fluctuate. Hospitals cannot give all their workers shots on the same day because of possible side effects and staffing issues, so they must be spaced out.

Rhode Island health officials said it can take up to seven days to get doses out to people once they are received. Officials in several states, including Rhode Island, Pennsylvania, Kentucky and New Jersey, said the lack of supply is one of the biggest obstacles to getting more people vaccinated.

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