It looked like a typical COVID-19 vaccination.
Deanna Arriola, a nurse who works at the hospital on Joint Base Lewis-McChord, took the day off and drove her red Toyota Highlander through the base’s drive-thru vaccine clinic. She got her shot within 20 minutes, and after running some errands, headed to her off-base home in Lacey.
But the record of her vaccination — the behind-the-scenes data that tracks who’s immunized — will stay locked in the U.S. Department of Defense computer system.
Due to a bureaucratic lapse, as well as legal and technical challenges, thousands of shots from two significant federal health care providers — the Defense Department and the U.S. Department of Veterans Affairs — have not been counted in official Washington state vaccination statistics.
That gap complicates the state’s response to the pandemic, and is artificially lowering the vaccination rate. Public health officials use the rates to target under-vaccinated communities with campaigns to overcome vaccine hesitancy.
The statistics took on more significance this week, as King County’s top public health official “strongly urged” everyone to continue wearing masks in public areas indoors, until 70% or more of residents age 16 and older are fully vaccinated. Other counties may adopt similar guidelines.
“We would very much like to have vaccination data info from the VA and Department of Defense, like all other vaccine providers in WA State are required to report,” Dr. Jeff Duchin, the King County health officer, said in an emailed statement, “so we can fully understand vaccine coverage rates and potential disparities across our communities.”
In recent weeks, federal and state legislators, along with the state Department of Health (DOH), have pressed the military and the VA to share detailed patient data. So far, the agencies have only shared aggregate numbers for vaccinations, making it impossible for the state to weed out duplicate records that might be coming from other health care providers.
Here’s an example of why the DOH can’t use the aggregate numbers: after getting a shot on base, a patient might later visit a primary care doctor outside of the federal systems, and that doctor could update his or her record in the state immunization registry.
Without identifying information, the DOH has no way of knowing if that person would be counted twice in the federal and state data.
More than 600,000 active-duty military and veterans live in the state — about 8% of the population — as of 2018, the most recent year for comprehensive federal statistics. Washington has the seventh-largest active-duty military population in the U.S., from Naval Base Kitsap with its nuclear-armed submarines, to the nation’s largest air tanker-refueling wing at Fairchild Air Force Base near Spokane.
While not all are treated at federal health care facilities, the patient populations are significant. The Puget Sound VA Health Care System alone has 110,000 patients enrolled in primary care. Family members and civilian military workers can also receive shots on base.
Washington is not alone in the struggle to incorporate the federal agencies’ immunization data, both for COVID-19 and other infectious diseases.
“This is a challenge that has been around for some time,” said Claire Hannan, executive director of the Association of Immunization Managers, which represents public health agencies nationwide. “We raised it going into the pandemic that this would be an issue.”
A major obstacle, Hannan said, is the difficulty syncing the VA and Defense Department electronic medical records with immunization registries in all states and territories, most of which have customized systems.
While preparing for the release of the COVID-19 vaccine last year, the U.S. Centers for Disease Control and Prevention discussed acting as a clearinghouse for all vaccine providers, including federal agencies, and then sending the data to each state’s system, Hannan said. But that second part — sending the records downstream to the states — never materialized.
After a Wednesday call with staff members from Washington’s congressional offices, Lt. Col. Luke Mease, chief of preventative medicine at Madigan Army Medical Center at JBLM, said the base would continue to work with the DOH to provide useful data. Representatives from Gov. Jay Inslee’s office and state legislative offices were also on the call, Mease said.
“We understand policy decisions are being made based on vaccination rates,” Mease said. “We want to be as transparent as possible from a public health perspective. Diseases don’t care if you’re on base or off base.”
Initially, JBLM officials believed the CDC was providing the state DOH with their patients’ vaccine data, Mease said, but they learned the federal agency was not.
Locally, JBLM had been giving Pierce and Thurston counties’ public health agencies the total number of COVID-19 doses received and administered. Mease said the base needs permission from Defense officials for any local or state data sharing.
“We discovered what we were sharing wasn’t as useful as we thought,” Mease said.
The Tacoma-Pierce County Health Department estimates if VA and JBLM vaccinations were added to its totals, the county vaccination rate would increase by roughly 4 to 5 percentage points. As of Wednesday, 30% of Pierce County residents had been fully vaccinated, excluding the federal agencies.
Active-duty members aren’t yet required to be vaccinated, but many have opted to do so. As of this week, 45% of people who live on base or work at JBLM have received at least one COVID-19 shot, according to a spokesperson for Madigan. Adding in family members, the total JBLM population is roughly 110,000.
The DOH sent a letter on May 5 to the Defense Department requesting detailed data, but state officials said they have not heard back from Washington, D.C.
“Probably here it is more of an impact than places without as much military presence,” said Jennifer Coiteux, acting director of the state DOH Office of Immunization and Child Profile. “It is really challenging to know whose information we have and whose information we don’t have.”
On Monday, JBLM gave state officials a breakdown of partially-immunized and fully-immunized residents from each of Washington’s counties. But that aggregate data is still not detailed enough to use in official vaccination rates, a DOH spokesperson said.
Typically, vaccine providers record a shot in the state Immunization Information System, which also keeps a history of each resident’s childhood vaccines. The DOH pulls address and demographic data from the system to compile its COVID-19 statistics.
But VA or military clinics do not enter shots into the state system.