How GPs are delivering thousands of ‘extra’ COVID vaccine doses

Jolyon Attwooll

9/09/2021 5:47:39 PM

A technique to extract supplementary doses from Pfizer vials has allowed thousands more people to be vaccinated despite stretched supplies.

A hand extracting a dose of Pfizer.
Using low dead-space needles, a seventh dose can be extracted from Pfizer's COVID vaccine vials. (Image: AAP)

‘The impact is just so major.’
That is Dr Anna Pham’s verdict on a method being used at her respiratory clinic to extract an extra dose out of Pfizer’s COVID-19 vaccine vials.
A GP in Picton, south-west New South Wales, she says the technique is allowing more people to get vaccinated at a crucial time, and with limited supply.
‘For us at a general practice level, we’ve been able to move people that had a three-month wait into a two-week wait – we’ve pulled them forward,’ Dr Pham told newsGP.
The technique uses low dead-space needles and was identified by the GP ahead of her clinic’s first Pfizer shipment in an online instruction module.
While Dr Pham says it can be a ‘little bit more fiddly’, she says it has had an enormous impact on the clinic’s vaccination rollout, by allowing staff to extract a seventh dose from vials which officially contain six.
‘We’re close to a 100% success rate,’ Dr Pham said. ‘It’s only if we hire someone new to the team that we have to train them in the technique to be able to get the consistency.
‘Once the initial training sessions have been done, they get the seven quite consistently as well.’
Official product information, as well as guidelines published by the Therapeutic Goods Administration (TGA), instruct vaccination staff to use 0.3ml per dose and explicitly do not permit any mixing of the vaccine from separate vials.
‘If we do not get the whole 0.3ml out for that seventh dose, we throw it – that’s unnegotiable,’ Dr Pham said. 
‘It has to be a full 0.3ml in every single dose, no short-changing in the first six to get a seventh. If it’s not 0.3ml, it gets discarded.’
With a respiratory clinic allocation of the vaccine, Dr Pham estimates current extra doses at more than 100 a week. Once the clinic’s allocation increases later this month, the total number of additional patients they could see per week could be pushing 200 – and that is just one clinic.
The Picton GP and her colleagues are far from alone in embracing the potential for extra doses. The possibilities have also been explored in the United States, where the extraction of extra doses has been widely reported.
Many other general practices in Australia are now doing the same, or expressing strong interest in following suit.
There have been instructions posted on WhatsApp groups, as well videos posted on social media and YouTube on the best way to get the most out of each vial.

RACGP NSW&ACT Chair Associate Professor Charlotte Hespe was an early advocate, while Dr Mukesh Haikerwal – whose clinic in Melbourne’s west was the first general practice in Victoria to start administering Pfizer – told newsGP that getting seven doses out of a vial is becoming increasingly common.
RACGP Rural Chair Dr Michael Clements also reports the technique as having a big effect on his Townsville practice.
‘Because of it, we’ve been able to vaccinate hundreds more people, so it’s worth the time and effort,’ he told newsGP.
It has not been possible, however, to quantify exactly how many extra doses have been administered across all Australian general practices as a result of extracting a seventh dose.
Most GPs did not come on board to deliver the Pfizer vaccine until July, with hundreds more practices set to join the rollout this month.
A Department of Health (DoH) spokesperson confirmed to newsGP more than 2.57 million Pfizer doses have so far been delivered through primary care, meaning the majority of the nearly 11 million doses have been administered by state-run hubs.
However, protocol has prevented some state-run clinics from drawing a seventh dose, newsGP understands, meaning a significant number of doses have potentially been wasted.
Of the guidelines provided by state health departments, only one – Queensland Health – explicitly references the possibility of a seventh dose in instructions that were updated late last month. Most also only require five doses to be extracted as a minimum, depending on the type of needle available.

However, a Queensland Health spokesperson told newsGP that while the guidelines acknowledge the potential for a seventh dose, it is very rare for one to be extracted
While supply issues with Pfizer are unlikely to be as acute following the announcement of a four million dose swap deal with the UK, Dr Pham is steadfast about the impact of the technique.

She hopes to persuade as many other medical professionals as possible to do the same, with millions of Pfizer vials due to arrive in Australia in the months ahead.
‘We are completely proud of the fact that this is a possibility. You just do the numbers and you see the impact,’ Dr Pham said.
‘I realised the impact [of] … the entire general practice community being able to do this for the nation, [and] I am absolutely promoting it and encouraging everyone to assess their technique and do it consistently.
‘With so many hesitant people now being ready [to have a COVID-19 vaccine], we get out of this lockdown quicker – it’s a no brainer for sure.’
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Dr Lee Ching Lim   11/09/2021 9:24:18 AM

I do have concerns about the medicolegal implications as this method is not approved by the TGA. Personally I think all doses should be formally allowed and endorsed.This is certainly a grey area. We gps see the whole picture and act for the good of the community.

Dr Min Fang   11/09/2021 4:47:58 PM

Good on you! Dr. Anna Pham! To save lives is our primary purpose in practicing medicine. And yes, this is a grey area from a medicolegal point of view. But what is the possible legal implication for doctors to pursuade patients to take a vaccine which is only provisionally registered over a vaccine that has obtained full FDA registration? How safe are we to suggest patients to shorten the duration of a 3 months manufacturer’s gap between doses to 1-2 months when its effectiveness statistics are based on the 3 months interval? Currently 70% of the over 16 year old population has received one dose and at least half of them have been fully vaccinated. 10 million Moderna + 40 million Pfizer = 50 million doses, the majority of which are coming in this final quarter of the year. With those figures, currently, I find it hard to convince the above 60 that their only option is AZ. This is not to say which vaccine is better, it is about equal access and freedom of choice.