The brand new vaccination center in Saarbrücken, in western Germany, was set up in record time in two old exhibition halls. With a dozen check-in counters, two large waiting rooms with hundreds of chairs, 36 separate cubicles and doctors at the ready, the center has all it needs to welcome crowds of people in an orderly fashion. The problem, as German daily Die Welt reports: No one has turned up.

Only 200 people per day were being vaccinated in the center this week, one-tenth its capacity.

According to the latest daily update from the Robert Koch Institute, Germany has vaccinated around 239,000 people since starting its campaign on Dec. 27, well short of the 1.3 million doses that were delivered by the end of 2020.

It was the Christmas miracle the world was waiting for: Multiple vaccines for a pandemic that had plagued countries across the globe for the better part of 2020. However, the reality of implementing an unprecedented global vaccination campaign has fallen far short of miraculous in many countries.

Inoculating billions of people was always going to present almost insurmountable challenges, particularly so with a vaccine that must be kept at extremely low temperatures and requires a second booster shot within weeks. While many countries simply don't have enough doses on hand, others are facing healthcare staffing shortages; a lack of infrastructure, especially in rural and underserved areas; and growing anti-vaccination movements. Here are some of the biggest hurdles:

1. Distribution chaos: In the United States, the lack of a federal roll out plan has left it up to individual states to figure out vaccine distribution, including who should be given priority. A last minute executive order from Florida Governor Ron DeSantis allowing anyone age 65 and older to get a vaccine left Canada's so-called snowbirds flocking to Miami to be inoculated.

• The state has one of the highest populations of elderly in the country and many of its 4.5 million seniors are camping out in the cold for a vaccine. As Broward County Mayor Steve Geller tells NBC Miami, "Many seniors are panicking because they think they were promised the vaccine immediately. They were not, but now they feel that faith has been broken."

• Lacking their own infrastructure, some local governments are even turning to the ticketing service Eventbrite to make vaccine appointments, as reported by Vox. Other medical service providers are using Facebook events and Google Docs in lieu of creating their own appointment systems. While this might raise security concerns (there have been fake Evenbrite pages), it eliminates the inevitable crowds of the first come, first served model.

2. Nobody in charge: Sweden was another country without a clearly defined national vaccination strategy. In an opinion article published in Swedish daily Aftonbladet, opposition party Kristdemokraterna lashed out against Sweden's ruling center-left coalition for failing to act preemptively. Kristdemokraterna warned that Sweden might end up last in line for a vaccine.

• At the heart of this problem is the fact that Sweden appointed a national vaccine coordinator who doesn't have a mandate to negotiate with medical companies. As Sweden lacks the domestic production capacity to meet the national demand for a vaccine, the country is dependent on international manufacturers.

3. Rural delivery delays: The world's second largest country in terms of landmass, Canada faces unique logistical hurdles in delivering its vaccine. More than 420,000 doses have been delivered to the provinces, but only around 28 percent have been administered.

• "It's an utter failure when you have three-fourths of our vaccines still sitting inside of freezers," biostatistician Ryan Imgrund, who works with Ottawa Public Health, told Global News.

• In Ontario, Canada's largest province, only around 5,000 people a day are being vaccinated, meaning it would take eight years to immunize the entire province. Ontario previously had the goal of vaccinating 8.5 million people by June, more than half of its 14.57 million population.

Defrosted vaccines being packaged for the start of the delivery — Photo: Pool Olivier Matthys/DDP via ZUMA Press

4. Safety issues: While India has approved two vaccine candidates, questions remain around their efficacy, especially for more vulnerable populations. AstraZeneca made a deal to manufacture its vaccine through the Serum Institute of India. But a trial participant who experienced neurological side-effects from the vaccine is suing the Serum Institute, while AstraZeneca is facing legal challenges in the UK for cherry-picking data. The other vaccine known as COVAXIN is developed by Bharat Biotech in collaboration with government agencies and is based on an inactivated form of the coronavirus. The company has completed only two of three trial phases. The third, which crucially tests for efficacy, began in mid-November.

• Consequently, it is the elderly who will both be the first to get the vaccine and potentially face side effects, as the vaccines weren't tested to see if they prevent severe forms of COVID-19.

• As Vasudevan Mukunth wrote in The Wire, "In other words, by messing up its validation process, the government is virtually experimenting with the most vulnerable cohort who will receive the vaccine candidates first – people like our grandparents, etc. – while those who are less likely to suffer for it will have it easier. And that is wrong, surely."

• There are challenges for the elderly in Italy too. The senior population there faces challenges to access the vaccine delivery points. One hospital in Rome has begun to dispatch mobile units of medical professionals to reach the most remote places.

5. Supply shortages: "The problem is that Europe doesn't have its own vaccine," president of the Hauts-de-France region Xavier Bertrand told France Inter, pointing out the failings of the government. "We have half of the French population who wants to be vaccinated. ... when will these people be able to do it?"

• Bertrand added that he expected France to match the level of action of its British neighbor: "We also have a French vaccine, Sanofi, which must be developed."

• Le Parisien confirms that the EU had ordered 400 million doses from Sanofi, of which 90 million were to go to France. The company's delay in delivering the vaccine therefore threw a significant spanner in France's vaccination plans, leading some to question the government's choice to "go local" in terms of vaccine production.

• Additionally, an adviser to Prime Minister Jean Castex estimated that between 25 to 30% of the 200 million vaccines ordered by France were at risk of being lost, according to Le Figaro. 50 to 60 million doses could be rendered useless because of the need to store them at -70 °C, and carry out the injection within 5 days after being removed from storage. The country's decision to prioritize the elderly has also slowed down vaccination campaigns considerably, with nursing homes required to collect consent forms from their residents — a process that can be sometimes very long, as France Bleu reports.

6. Doctor shortages: Vaccination delays in the northern Italian region of Lombardy were blamed on doctors being on vacation. But Giulio Gallera, the region's head of welfare services, warned against hysteria in the first days of the vaccination program. "It's awful to see people ranking those who have vaccinated the most people so far, let's do it in 15 or 20 days," Gallera told La Stampa. "We have doctors and nurses who have 50 days of overdue leave. I won't force them back from their holidays to perform vaccinations. But we will stay on schedule."

• In Spain, 82,834 doses of the Pfizer vaccine had been administered by January 4. In total, the country has received 718,575 doses, of which 360,000 have been received yesterday (despite the campaign starting before the Christmas holidays). The lack of health professionals exacerbated by the Christmas holidays have slowed down the administration of the vaccinations for a week in much of the country.

• There have also been production problems by the multinational manufacturer Pfizer manufacturer. And then there was the eruption of the new virulent strain of the virus in Great Britain and the subsequent border closures, the unpredictable logistics of several communities, lockdowns, curfews, school closures, healthcare systems being overwhelmed...