“We’ve made it so complicated”: Vaccine campaigns are failing to reach the most vulnerable

The good news is that the rate of Covid-19 vaccinations in the United States is increasing, while the rates of new infections, hospitalizations, and deaths are slowing. As of this week, more than 66 million doses have been administered to at least 42 million Americans, about 13 percent of the population.

But the disease is still spreading, and there aren’t yet enough vaccine doses to meet demand. And many who need a vaccine the most are having the hardest time getting one.

From signing up for appointments to securing transportation to clinics, many of the people at the highest risk for severe outcomes and death from Covid-19 — older adults, essential workers, and minority communities — are having trouble getting vaccinated when it’s their turn. At the same time, some wealthier people or people at lower risk have gamed vaccine registration systems to get to the head of the line.

“A lot of my older patients are struggling to figure out how to do it in general,” said Margot Savoy, chair of the family and community medicine department at Temple University in Philadelphia. “We’ve made it so complicated.”

Right now, the priority for many states is scale. Some are setting up mass vaccination sites at public venues like stadiums to get as many shots into arms as possible, as fast as possible. However, some health experts argue that in addition to going big, communities should also go small, working through local clinics and community groups in order to reach the most vulnerable. It may come at the expense of speed, but it would help ensure equity in who’s getting vaccinated for Covid-19.

Vaccinating the most vulnerable people requires active outreach

No community or demographic has been spared from the Covid-19 pandemic. More than half a million Americans have died from the disease, and many more have gotten sick. But some groups are getting hit harder than others, and it’s not just the elderly.

“Throughout the pandemic, people of color have consistently been disproportionately sickened and killed by the virus,” wrote Youyou Zhou and Vox’s Julia Belluz in a recent piece. “They also died young: Of Covid-19 deaths in people under the age of 45, more than 40 percent were Hispanic and about a quarter were Black.”

These same groups are also less likely to interact with the existing health care system and are more likely to face impediments when seeking the vaccine. Technology is one barrier that’s emerged in several states. For example, the online booking system for vaccine appointments in Arizona seems to be favoring some groups over others.

“When appointments become available, it’s like a gold rush,” said Will Humble, executive director of the Arizona Public Health Association and a former state health official. “If you work at a grocery store or don’t have wifi, you’re at a big, big disadvantage.”

Arizona has set up mass vaccination sites around major metropolitan areas. That’s helping the state boost its numbers — about 15 percent of its population has now been vaccinated — but many of its most vulnerable people haven’t been able to sign up for the limited appointment slots during the few short hours when they’re open. Some also aren’t able to drive to these sites from their homes, according to Humble.

“The effect of that [mass vaccination strategy] was yes, it did speed up the administration of vaccine, but it also has disproportionately served high-income people,” Humble said. “What vaccinators tell me is they are vaccinating Teslas and Tahoes all day.”

According to a Kaiser Family Foundation assessment on February 18, about 12 percent of Arizona’s white population has been vaccinated so far against Covid-19, compared with 4 percent of Black people, 3 percent of Hispanic people, and 9 percent of Asian people.

Another issue for Arizona, like in many states, is that remote regions may not have the resources to administer both of the Covid-19 vaccines that are currently available in the US. While the Moderna vaccine has less stringent freezer demands, the Pfizer/BioNTech Covid-19 vaccine requires ultra-cold storage, so it’s being allocated mainly to larger counties that have the facilities to store it.

Humble said that one way to improve the system would be to have a one-time sign-up and then a weighted lottery to allocate appointments, so people with fast fingers, fast internet connections, and free time wouldn’t have such an overwhelming advantage.

But getting to some of the most vulnerable also requires active outreach. “We’re doing a real grassroots approach to this, which requires us going to the communities … literally knocking on doors,” said Tomas Ramos, the founder of the Bronx Rising Initiative, a group helping vaccinate Bronx residents against Covid-19. “What I get when I knock on the door and speak to an elder, they just don’t even know when to start. That’s where we come in.”

Bronx Rising Initiative is working on raising funds for local clinics to increase capacities for Covid-19 vaccination, and also for setting up remote vaccination sites in public housing. In addition, the group is seeking out seniors and other vulnerable people to sign up for vaccine appointments, following up with reminders and helping them arrange transportation if needed.

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Many of the initiative’s volunteers are from the Bronx, too. And that helps build trust, fight vaccine misinformation, and coax reluctant Bronxites to get immunized.

“We are from the community, so when [volunteers] knock on the door, [residents] see someone that lives in the same community talking to them about it,” Ramos said.

Local health clinics can close gaps in vaccinations, but they need doses first

Many communities around the country have had months to set up their programs to administer Covid-19 vaccines. But supplies remain limited, and there is a frustrating lack of information about when they’ll be replenished.

“We have the whole infrastructure to give it,” said Julie Vaishampayan, the public health officer for Stanislaus County in California. “We’re getting it out into pretty good arms, but we’re not getting it out to every eligible arm and we’re not quite sure who we’re missing.”

Another complication is that local health officials have to jump through hoops to order vaccines from the county, state, or federal government. And it’s not always transparent where these vaccines are going, so health workers on the front lines don’t have much time to prepare. When vaccines do arrive, local health officials have to identify eligible recipients, round them up for appointments, administer the shots before they expire, and keep track of patients to make sure they get their second doses. There can be overlap between different areas of health coverage, so even if someone is a perfect candidate for a vaccine, it can be hard to tell which group or agency is in change giving them a shot.

“I can’t see the vaccine that’s coming from the federal government or the state government,” Vaishampayan said. “I don’t know who it’s going to. I don’t know how many doses they’ve received. I don’t know how many doses they’ve given. It makes it really difficult to set up a network or providers who are going to reach your population.”

A central information hub that tells local health officials how vaccines will be allocated up to a week in advance would go a long way toward optimizing distribution, according to Vaishampayan. Currently, many health departments have to deal with much shorter lead times for receiving vaccines.

One potential bit of good news is that the Covid-19 vaccine developed by Johnson & Johnson may get emergency approval from the Food and Drug Administration this weekend. Not only would a third vaccine help bolster the supplies, the Johnson & Johnson vaccine requires only one dose instead of two and can be stored at ordinary refrigerator temperatures.

That vaccine would be particularly suited to smaller family practices and community clinics, which are less likely to have ultra-cold freezers. These types of facilities may have a lower throughput of vaccinations (since they are equipped to handle fewer patients and may not have the facilities to stockpile vaccines), but they may be able to better identify the people in greatest need of a Covid-19 vaccine.

Having a one-dose Covid-19 vaccine that can be stored in an ordinary medical refrigerator would allow these clinics to join in and expand the scope of the vaccination campaign.

“When we get to that vaccine, all of sudden there is a real opportunity for the average family doc or primary care person,” said Savoy. “If we ever had a vaccine to actually distribute and had one we could have at the practice and store it, we would have a whole network of people ready to go.”

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