Earlier this month, shortly after Pfizer announced that its vaccine was 90% effective in preventing COVID-19 in a clinical trial, New Jersey physician Linda Girgis tweeted to her patients: “As a family doctor, I’m seeing whole families infected with #COVID19. Please #WearAMask and keep #SocialDistance. A vaccine is coming soon.” 

But despite her hopeful message, Girgis doesn’t think she’ll be able to administer the Pfizer vaccine to her patients. The much-awaited remedy comes with many logistical caveats. The vaccine is expected to be shipped in quantities of 1,000 to 5,000 doses and requires specialized freezers, which can range from $4,000 to $10,000 — too pricey for independent providers — because it must be kept at -112 degrees Fahrenheit. “I am in a small practice with my husband, and we don’t have the capability to store vaccines at this temperature,” says Girgis, who plans to refer her patients to a facility with more resources, possibly a pharmacy. “I think the cost is prohibitive for a lot of us.” Handling something that must be kept at such temperatures requires training, she adds. “I don’t think I’d be able to do it myself.”

Girgis is not alone in her concerns. Storing and administering such a vaccine presents logistical challenges for many small practices and rural clinics. Some won’t be able to afford the freezers. Others who typically order vaccines by dozens rather than hundreds won’t be able to use 1,000 or more doses. There are additional issues: Electricity supply in some regions of the nation is unreliable, and winter weather can make traveling to clinics difficult. The vaccine also requires two doses administered 21 days apart, so patients would have to travel twice to get immunized. So, depending on which states, territories and climate zones health providers are located in, the challenges they face are as diverse as their environments.

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Leah Gilliam, a family medicine specialist at a small primary care clinic in Lexington, Tennessee, a rural town about two hours away from major urban centers, won’t be administering the vaccine to her patients either. Her clinic provides low-cost care that serves many uninsured patients, so she can’t afford the freezers. “Small offices won’t be able to accommodate that, and I certainly can’t,” Gilliam says. Any vaccine storage is a challenge for small practices, she adds, even those that don’t require super low temperatures. Because small clinics don’t have many patients, the vaccines often go past their expiration dates, so Gilliam typically refers patients to the local health department. In her case, there’s one five minutes down the road, but this additional stop can be an obstacle, particularly with a two-dose vaccine. The drive itself is not a barrier, but it’s just another step the patients have to take, and lots of times they end up putting it off, Gilliam says. “They just never get around to doing it.”

Ever since the Pfizer announcement, Ann Lewandowski, the co-chair of the State Disaster Medical Advisory committee on vaccine distribution and founder of the Wisconsin Immunization Neighborhood, which works to reduce vaccination barriers, has been on the hunt for an affordable freezer that health providers can buy. “A small thermal shipper has been a task of mine,” she says. When Lewandowski found that AeroSafe Global freezers that can keep the vaccines at the right temperature sell for less than $1,000, it made her day.

This article originally appeared on Medical Bag