Iowa opened the next phase for vaccine distribution during the first week of February. Phase 1B includes frontline essential workers as well as Iowans 65 and older.
But vaccine demand far exceeds supply, and has made rollout challenging, especially in the state’s many rural areas.
For more than seven years, the Girls State Training School in Toledo has sat mostly empty and unused. But on Monday, the school campus’ main building is buzzing on the first day of Tama County’s COVID-19 vaccination clinic.
Rooms that are still labeled for their previous tenants -- social workers, psychologists, administrators -- are now filled with health care workers, mostly volunteers, and elderly residents of the rural county of about 18,000.
"It's zooming today," said Shannon Zoffka, the executive director for the Tama County Public Health Department. "We've noticed that despite our best efforts to say come at your scheduled time, people are coming 10 to 15 minutes early."
Zoffka said the clinic is scheduled to give 110 people their first doses on Monday. They’ve been selected from a waiting list her department started at the end of January.
But aside from the excitement in the air, Zoffka said her small staff is stressed. They have the ongoing difficult task of maintaining this waiting list while making a small number of appointments to dispense a limited number of doses.
"Once it gets here, and you get rolling. There's just a lot of unknowns, too, with how many doses are we getting? How many people can we actually vaccinate?" she said.
Zoffka isn’t the only rural health department director feeling overwhelmed right now.
Chris Estle, the administrator for the Jefferson County Public Health Department, said when word got out her department was scheduling appointments for this week, they filled up 180 slots in about three hours.
"We never could get all the voicemails called back because we could hold 100 voicemails," she said. "We couldn't even get through all the voicemails."
Estle said 24 percent of Jefferson County’s population is 65 and older. Like many rural counties, that’s higher than the statewide average of 17.5 percent. But she’s not keeping a waiting list. She said it’s too complicated with rapidly changing information coming in.
Estle said they’re scheduling first come, first served appointments as doses come in, but this has pushed some to call or contact her directly through her personal Facebook account.
"Nope, not even starting that. Not even going to go down that road," she said. "So you have to set professional boundaries, and that's very, very difficult in a small rural community."
All Iowa counties are currently facing a large demand for a relatively small supply, and Iowa ranks close to last in the nation for vaccine allocation and administration per capita.
At a Thursday press conference, Gov. Kim Reynolds said state officials are reaching out to counties and health care providers to see what's slowing down the process.
"They're hesitant to schedule appointments when they're not sure if they're going to get their allocation next week, because it's been — you know, that's been a variable from the from the federal administration as well," she said.
One issue could be that Iowa has many rural areas.
Tinglong Dai, a professor of operations management at Johns Hopkins University, said these areas have additional obstacles for the rollout.
One is that most of them just don’t have the ultra cold storage for the Pfizer vaccine, which accounts for more than 40 percent of the doses administered in Iowa so far.
"I think we need to really think carefully about equity," Dai said. "So equity does not just mean the quantity of vaccines allocated to each area, it also means what kind of vaccines people are getting."
Dai said to address the current short supply issue, Iowa should follow the lead from another rural state -- West Virginia, which registers qualified residents at the state level and gives them a place in line to avoid overwhelming smaller departments.
Reynolds said Thursday the state is seeking a partnership with a vendor to create a call center for vaccine information and a centralized database for Iowans to register for the vaccine.
"I don't think people really want to get vaccines like the next day, the next hour. People just want to get that kind of assurance," Dai said.
That assurance is what Linda Robbins wants. She's a 69-year-old resident of Epworth, a town of about 2,000 in Dubuque County.
Robbins said she hasn’t heard anything from her county about how to get vaccinated, while several of her friends in Des Moines have gotten appointments at places like Hy-Vee.
"Tell us something. You know, just let me know. I mean, I know there's a shortage, and I know I'm probably not going to be first, but just tell us what the plan is," she said.
At the Girls State Training School in Toledo, 67-year-old Tama resident Debra Behounek got her first dose of the Moderna vaccine along with her husband and aunt on Monday.
Behounek said she feels incredibly fortunate to get her family vaccinated this quickly. She said she just happened to get on the Tama County list early when she came across a Facebook post from the health department.
"You know, when you watch across the country, everybody, waiting and waiting. And then it's just this is a miracle. We got the first day," she said.
Behounek said she would have been happy if her family got vaccinated by June.