All eyes are on the nation’s chaotic COVID-19 immunization rollout, as public health officials struggle to outpace the coronavirus and its variants by quickly inoculating those most likely to be hospitalized or die if infected.
But in the months ahead, as the vaccine supply chain unkinks, the demand for shots is expected to ebb, leaving public health agencies with a different and perhaps greater challenge—coaxing people who aren’t sure they want a shot to roll up their sleeves.
The goal is to reach herd immunity, a widely debated concept that most scientists say can be achieved by vaccinating roughly 80% of the adult population, leaving the coronavirus with so few hosts that it all but disappears.
“We’ve never done that before with any other adult vaccine,” said Dr. William Schaffner, professor of preventive medicine at the Vanderbilt University School of Medicine. It’s a worthy goal, he said, but it will take a monumental effort.
In some places, local health departments already are making inroads in minority and immigrant neighborhoods where people may mistrust the medical community and refuse vaccinations, he said.
But even within the priority groups designated in the federal Centers for Disease Control and Prevention’s guidelines—health care workers, long-term care residents and staff, and people 65 and older—a substantial number of people are holding back.
According to January survey data from the Kaiser Family Foundation, a San Francisco-based nonprofit that researches national health issues, roughly 3 in 10 health care workers express hesitancy about getting a COVID-19 vaccine. That proportion is higher for staff in long-term care facilities, where 6 in 10 health care workers did not get a shot during the first month of vaccine distribution, according to the CDC.
Vaccine hesitancy is lowest among people 65 and older of all races, with only 10% of older White people and 14% of older Black people saying they plan to wait and see whether the shots cause serious side effects before rolling up their sleeves, according to Kaiser.
“The more people we vaccinate, the harder we’ll have to work to get the next group in,” Schaffner said. “Once we vaccinate the eager early acceptors, we’re going to have to go out and find people in the general population who haven’t lined up yet.”
When that happens, public health experts warn that states, cities and counties will face an array of challenges. Among them: reaching large immigrant and Black, Hispanic and Native American populations who mistrust the government, and combatting the disinformation that well-organized anti-vaccine groups are spreading across social media. Public health workers also will need to create pop-up and mobile clinics to vaccinate residents in rural areas and urban neighborhoods with limited access to hospitals, doctors and pharmacies.
“Figuring out how to get vaccines to people who can’t get to the clinics is only part of the problem,” Schaffner said. “The other part is the persuasion, the reassurance, the comfort that inherently reluctant populations need to come forward and get vaccinated. You have to work on both of those at the same time. That takes people and people take salaries.”
Johnson & Johnson’s vaccine, approved last week, may present another challenge. The vaccine doesn’t require a second shot, doesn’t need to be frozen and in a clinical trial it completely prevented hospitalization and death. However, it was only 66% effective in preventing moderate to severe cases, compared with the more than 90% effectiveness of the previously approved Pfizer and Moderna vaccines. (Unlike the vaccines approved earlier, however, the testing of the Johnson & Johnson vaccine took place as more contagious variants were circulating.) Some state and local officials worry that people will decline the Johnson & Johnson vaccine, so they can get one of the other vaccines instead.
Distracted and Underfunded
Under a law signed in the last days of the Trump administration, federal dollars appropriated by Congress for vaccination programs are only now starting to flow to public health agencies that have been underfunded for 15 years.
Roughly $3 billion is allocated specifically for immunization programs, and state and local agencies can use portions of another $19 billion in pandemic-related funding to support vaccination efforts, said Adriane Casalotti, government affairs chief at the National Association of County and City Health Officials, which represents local health departments.
But when the vaccines became available in early December, there was no plan and no money for distributing them, said Claire Hannan, executive director of the Maryland-based Association of Immunization Managers, which represents vaccination officials. Local health departments, preoccupied with COVID-19 testing and contact tracing, were charged with coming up with their own approaches to quickly and equitably distributing the life-saving shots.
Three months into the largest immunization campaign in American history, nearly 50 million people have received at least one shot. The next phase, Hannan said, will be much more challenging.
“We know we can’t just flip a switch and reach the people who didn’t line up for the vaccine from the start. We should have been reaching out to those populations all along,” she said. “We have to start now to deliver vaccines to communities where demand is low, particularly where residents already have borne a disproportionate share of hospitalizations and deaths.”
Some states already are taking steps to gain community trust and identify barriers to more people getting vaccinated.
Arizona, Vermont and Washington state, for example, are using a vulnerability index that includes census data on poverty, lack of transportation, crowded housing and other factors to identify particularly vulnerable populations, and tailor public health messages for them, according to a December study of states’ initial COVID-19 vaccination distribution plans.
Massachusetts, New Hampshire, Tennessee and the District of Columbia are using similar calculations to allocate a larger per capita share of vaccines to areas with the greatest need. And New Jersey is using a vulnerability index to decide where to place COVID-19 vaccination clinics, according to the analysis by researchers at the University of Pennsylvania, Harvard University, Georgetown University Law Center and Children’s Hospital of Philadelphia.
More broadly, Arizona, Missouri, Montana, North Carolina, North Dakota, Utah, Vermont, West Virginia and Wyoming prioritized Black, Latino and Native American residents in their COVID-19 vaccine distribution plans, according to the National Academy for State Health Policy.
But in Hannan’s home state of Maryland and in many others, elected officials are getting hammered by confused and anxious people in the top priority groups who want to get their shots as soon as possible. That’s distracting public health officials from doing the painstaking groundwork needed to build trust and identify partners in communities that are most vulnerable but less vocal, she said.
“If they don’t make a really concerted effort now, I fear that things will open up to more and more people but leave a lot of people behind who are more vulnerable and at higher risk of serious outcomes of the disease.”
Mistrust and Misinformation
Since the flu vaccine was first distributed in the mid-1940s, an annual average of about 50% of Americans have taken the shots. That’s despite the vaccine’s high degree of effectiveness, rare side effects and wide availability.
Every year, public health officials aim to vaccinate all U.S. residents older than 6 months. But in a typical year, they achieve only half that goal. Between 3% and 11% of the U.S. population contracts influenza each year, and in the past decade, there have been as many as 61,000 deaths and 810,000 hospitalizations annually, according to the CDC.
Flu vaccines are safe and effective at reducing influenza’s severity, hospitalizations and deaths, but the shots are only 40% to 60% effective at reducing a person’s chance of contracting the illness, according to the CDC.
As a result, many people have concluded that flu shots don’t work. That, combined with a pervasive myth that an influenza vaccination can make people sick or even cause the flu, have combined to stymie public health agencies for decades.
Surveys indicate that many people, particularly young adults, believe a flu shot isn’t worth the trouble since they rarely get the flu and when they do, it’s not that serious.
Some public health experts calculate that because the fear of contracting COVID-19 is greater than that for the flu, vaccination rates may end up being higher.
“Unlike the flu, COVID has been so devastating and novel that people are scared of it,” said Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials, which represents state health department officials. “As a result, I expect we’ll eventually get more people who want to be vaccinated for COVID than for flu.”
Nevertheless, according to Plescia, state health officials are concerned about vaccine hesitancy, especially in communities of color. “Where there are trust and education issues is where we can make a big difference in swaying people,” he said.
State officials are less focused on changing the minds of hardcore “anti-vaxxers,” a small but well-organized group of mostly White, educated, middle-class people who oppose vaccinations on principle, Plescia said. “Our biggest focus is trying to monitor those groups to see what they’re up to because of the harm their misinformation can do,” he said.
Among the most common form of misinformation related to COVID-19 vaccines are anecdotal rumors tying a person’s untimely death to the fact that they recently got a COVID-19 shot. Another myth alleges that the vaccine can cause infertility and permanently alter a person’s genetic code. Those allegations are false.
Now that millions of people have been vaccinated, including nearly 25 million who have received a second dose, experts at the CDC will be able to separate rare side effects caused by the vaccine from coincidental illnesses and deaths, explained Dr. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia, in an interview with U.S. News and World Report.
States have been widely criticized for failing to collect race and ethnicity data on the people who receive vaccinations. As a result, it’s unclear exactly what percentage of racial and ethnic populations are getting vaccinated.
According to Rebecca Coyle, executive director of the American Immunization Registry Association, which represents vaccination data experts, caregivers aren’t routinely asking for race information at bustling vaccination sites, nor are patients always willing to provide it. And in hospitals and clinics that use existing electronic health records, race information is often left blank and not updated, she said.
Public health professionals can combine existing data sets to determine race and ethnicity to analyze how well they’re doing in equitably distributing the vaccines, she said.
But in the meantime, ZIP code data can point to communities where COVID-19 infection rates and deaths are highest and vaccination rates are lowest, she said.
In Massachusetts, Republican Gov. Charlie Baker announced Dec. 16 that the state would spend $1 million on a targeted outreach initiative in the 20 cities and towns hardest hit by COVID-19. In cooperation with the Massachusetts League of Community Health Centers, which represents local family health clinics, the plan aims to make it easier for people to get vaccinated in those historically underserved communities.
“Massachusetts should have taken this approach much sooner,” said Shan Soe-Lin, a Yale University lecturer on global health and managing director of Pharos Global Health Advisors, a Boston-based nonprofit policy group. “It would have saved hundreds of lives and prevented thousands od illnesses.”
Soe-Lin and her husband, Robert Hecht, a professor of epidemiology at the Yale School of Public Health, have been critical of the Baker administration’s vaccine rollout. They argue that bringing vaccines to underserved neighborhoods and collaborating with trusted community leaders may take a little longer at first, but ultimately will get the nation closer to herd immunity without leaving the most vulnerable behind.
In every state, there are handfuls of towns of 40,000 to 90,000 people, such as Brockton, Chelsea and Revere in Massachusetts, that are responsible for the lion’s share of the COVID-19 cases, Soe-Lin said. “The easiest thing to do is to roll up with a mobile vaccination clinic and provide shots 24 hours per day until everyone, young and old, is vaccinated.”
Combine that kind of targeted approach with clinics in churches, schools and community centers and local drug stores, and the problem would be solved, Soe-Lin argued. “It would take only one or two weeks in each community,” she said.
Another way to reach people who can’t drive to mass vaccination sites, and who may be hesitant and want to talk to someone they trust before they get a shot, is to enlist family doctors, Soe-Lin said.
According to the Kaiser Family Foundation, 85% of people say they trust their own doctor most for reliable vaccine information.
Massachusetts decided early on not to send vaccines to family doctors and instead opted for remote vaccination sites that only people with cars can reach, Soe-Lin said. “With the highest insured rate in the country, nearly everyone in Massachusetts has a doctor or community clinic they can go to for a vaccination.”