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Scaling up a COVID-19 vaccine clinic

John Romeo, SCCAD’s deputy chief medical officer, shares the lessons learned from registering as a vaccine distribution site and recruiting vaccinators


A robust mobile integrated health division and a facility that could be utilized exclusively for vaccinations positioned SCCAD to handle the task of inoculating hundreds.

Photo/John Romeo

Reno, Nevada, is known as the “biggest little city in the world,” but in many ways, St. Charles County, Missouri, could be considered a close contender. Located 25 miles northwest of St. Louis, the county’s population numbers more than 400,000. Despite being home to three of Missouri’s top 10 most populous municipalities, a sense of community more common to small towns runs deep.

Given this, it’s no surprise the agencies working to protect residents within the county are deeply entrenched with one another. For St. Charles County Ambulance District (SCCAD), close working relationships with emergency management, public health, emergency communications, fire protection and law enforcement have been critical to our success.

From the onset of the COVID-19 pandemic, SCCAD’s leadership team has worked in tandem with the county’s incident commander, assisting with PPE procurement, testing and contact tracing among other duties.

Long before vaccine doses began shipping, SCCAD worked closely with St. Charles County Department of Public Health (SCDPH) to develop a plan that ensured every paramedic, firefighter and police officer who wanted the vaccine received it. A robust mobile integrated health division and a facility that could be utilized exclusively for vaccinations positioned SCCAD to handle the task of inoculating hundreds.

Registering as a vaccinator site

With supply unknown and demand expected to be high, SCCAD registered in November as a COVID-19 vaccination site independent of SCDPH with Show Me Vax, Missouri’s online immunization information system operated by the Missouri Department of Health and Senior Services. While possible for us to utilize doses procured via SCDPH, it made sense for SCCAD to receive our own to focus on the first responder population. Though the registration process was relatively straightforward, it was time-consuming, considering the required training modules on use of the online vaccine dashboards, storage/handling of the doses, reporting requirements and more.

As states began announcing phased deployment plans, SCCAD and other ambulance services in Missouri were surprised to find EMS in Phase 1B vs. 1A. A provision of the state’s plan, however, allowed local health departments to adjust phases/tiers to meet unique community needs. SCDPH shifted EMS to 1A, with the justification that paramedics would serve as vaccine administrators. Missouri later revised EMS’s statewide position to 1A.

Recruiting vaccinators

To ensure we procured an adequate quantity of doses, the district conducted a questionnaire via SurveyMonkey of each first responder agency within the county to determine what percentage of the workforce was interested. SCCAD employees received a modified survey with a question inquiring whether they would be willing to receive their vaccine early from public health so they could serve as a vaccinator when additional doses became available. Levels varied slightly between departments, but generally, agencies reported a 65-70% interest rate from those who responded.

SCDPH received its initial shipment of Moderna vaccine just after Christmas, and allocated doses to paramedics who had agreed to serve as vaccinators. These paramedics began assisting SCDPH with vaccine administration at their mass vaccination events in early January, and later served as vaccinators at our first responder clinic.

COVID-19 vaccine administration logistics

On January 18, the anxiously-awaited email arrived – 975 doses of Pfizer COVID-19 vaccine would be delivered the following day. An EMS station that SCCAD recently vacated became ground zero for the first responder vaccination effort, and in a matter of 24 hours was ready for use as a clinic.

SCCAD, fire and police personnel received a link through the scheduling platform Signup Genius to register for appointments, which began on January 21.

Logistically, we found that clinic operation requires seven paramedics. Four appointments are scheduled at 20-minute intervals for a total of 12 per hour. The allocation of duties is as follows, and can be scaled:

  • One paramedic works check-in, processing vaccination screening paperwork and answering questions
  • Each of four vaccination stations is staffed by a paramedic who reviews pertinent information, administers the dose and collects information for the patient care report
  • One paramedic works the monitoring area to ensure that any potential adverse reactions are quickly identified and treated – this individual is also charged with scheduling second doses
  • One MIH captain oversees the operation, assisting wherever needed

While there is no cost for the medication, we collect insurance information to bill for administration to recoup personnel costs. Following Cares Act guidelines during the public health emergency, no co-pays or out-of-pocket payments are collected.

As a registered vaccination site, we are required to report to Vaccine Finder (operated by the Centers for Disease Control) weekly, and to Missouri’s Show Me Vax web portal daily.

Worth noting are the logistics surrounding the storage of these super-cooled vaccines. The vaccine manufacturers provide detailed directions on how the vials are to be stored and re-iced to ensure doses remain stable. Said directions must be followed carefully at prescribed intervals, which may require trained individuals to be available on days they’re normally off.

SCCAD paramedics wrapped up first dose operations yesterday, having administered 1,110 doses to paramedics, firefighters, police officers and others who met criteria.


From the onset of the COVID-19 pandemic, SCCAD’s leadership team has worked in tandem with the county’s incident commander, assisting with PPE procurement, testing and contact tracing among other duties.

Photo/John Romeo

Challenges faced in vaccine distribution

Though the operation came together quickly, it functioned well considering the scope of the initiative. That said, there have been challenges that required us to expedite some facets of our plan, and revise others. Most notably, several first responder agencies that we accounted for in our order total were presented with opportunities to get staff vaccinated prior to SCCAD doses arriving.

These opportunities were varied – in some cases, hospitals throughout the county (who received their doses in early January) had small quantities of doses left at the end of staff vaccination events. Rather than waste them, hospitals contacted fire/police to prevent waste. Also, a private agency that obtained approval as a Show Me Vax site reached out to some law enforcement agencies in mid-January offering to vaccinate officers.

It’s difficult to fault our partners for taking advantage of these opportunities when presented with them, particularly given the fact that we were unable to assign a firm timeline on when our doses would arrive. If we’d been provided a firm date on shipping in advance, we could have communicated this to our partners.

Thankfully, when developing our strategy, we built contingencies to ensure all doses would be utilized. Inoculating fewer first responders than expected expedited the following:

  • Initially, availability was limited to first responders who had never had COVID-19 or were outside the 90-day immunity window. We relaxed this requirement, enabling those who had the virus more recently to be vaccinated.
  • Though we anticipated serving primarily first responders, we are not required to focus solely on this group. We next enabled SCCAD staff to allow immediate family who fell into Missouri Phases 1A and 1B (Tiers 1 and 2).
  • Several days later, we extended the same opportunity to firefighters and police officers, asking that each person register no more than two contacts.
  • As a final contingency, we obtained authorization to transfer doses to SCDPH prior to their expiration, should any remain.

Tips and takeaways on COVID-19 vaccine distribution

  • Simplistic technology (Survey Monkey, Signup Genius) offers intuitive, mobile-friendly operation, but a more secure method may be preferable. We experienced instances of the link being forwarded to those beyond the intended circle of family/close contacts. Some who gained access did not meet criteria and were turned away.
  • Develop multiple contingencies that allow you to quickly expand your reach to individuals who fall within your state’s phase/tier system.
  • Develop a standby list comprised of individuals who live very near your vaccination site – if you get to the end of the day and have doses thawed that must be used, call upon these individuals to quickly report for vaccination.
  • If you are not a vaccination site for the public, train your staff on where to direct those who may call/text/email to inquire about vaccination – point these individuals to a health department, hospital or pharmacy registration pages as appropriate.

Read next: Vaccine storage: An EMS guide to dry ice-handling and hazards

John Romeo is deputy chief medical officer for St. Charles County Ambulance District. He can be reached at