Our national recovery from the Covid-19 pandemic depends perhaps more than anything else on a nationwide vaccination campaign that will have to be bigger, faster and more comprehensive than any previous public health initiative in our history.
Which is to say — it’s going to be complicated. President Joe Biden has pledged to administer 100 million shots in his first 100 days, a lofty goal that even if met will still cover just a fraction of Americans. It’s already run into problems: States got off to a sluggish start in December amid fewer-than-expected doses and confusion over their allotments; the federal plan to prioritize health care workers and elderly populations broke down in practice; and news reports suggesting states were hoarding doses generated bad press. Meanwhile, the health care system is quite literally racing against time, trying to get a critical mass of Americans vaccinated fast enough to halt mutations that could render the vaccines less effective.
What’s more, it only gets harder from here. Over the next few months, the supply of vaccines will grow, but so will the barriers to getting those shots in the arms of enough Americans. The health system will need to make a sharp pivot from vaccinating eager populations like health care workers and older adults to those who are harder to reach: the under-served, the skeptical and those who live in remote areas.
“Supply will remain the limiting step for next month or two,” said New York City Health Commissioner Dave Chokshi. “Then we’ll be grappling with a different problem, with regard to demand.”
The good news is that states and cities are solving these problems in real time, trying new strategies and quickly recalibrating and implementing what works. So POLITICO decided to convene a “policy hackathon” — Zoom sessions in which we asked some of the sharpest public health experts from around the country to compare notes, identify emerging challenges and share the best ideas for making this complex vaccination effort work.
Our nine policy hackers — who came from big urban cities like New York City and Newark, as well as from rural states like Montana and West Virginia — said they have already learned important lessons about what works. Over the course of the discussion, some raised vexing challenges for which others were able to provide solutions. And they pointed to some key areas where their federal counterparts could significantly accelerate the effort by shifting priorities, providing better data and perhaps most importantly, do a better job communicating how and why vaccination is important, before it’s too late.
Here are their takeaways.
PART 1: WHAT’S GONE WRONG
Every state and locality has its own mix of challenges. In some areas, dense populations make Covid-19 easier to spread. In others, vast distances make delivering vaccines logistically complicated. Some places have a lot of older adults, while others have more Black, Latino and other minority residents whose death rates have been high but who may have less access to vaccination sites.
One huge tradeoff state and local officials identified is between efficiency and equity; it’s faster to use online registration portals and mass vaccination sites, but those methods leave out vulnerable residents, including minorities and frontline workers who lack access to broadband, flexible work hours or reliable transportation.
Despite the differences in their challenges, POLITICO’S policy hackers expressed agreement on some key problems that have hampered vaccination programs nationwide.
Poor information about Covid-19 vaccine deliveries.
Participants said that perhaps the biggest and most universal problem they faced was a lack of clarity on how much vaccine they would receive and when it would arrive. The confusion makes it difficult to plan vaccination sites, operate appointment systems and sketch out projections for priority groups, leading providers to hold back supplies — to ensure second doses — even amid crushing national demand.
Biden announced in January that his administration would bump up weekly supplies and give states up to three weeks’ notice on their allocations. Officials said that is helpful, but they really need more than three weeks to organize logistics, and they don’t believe there’s a good reason the federal government can’t provide more notice.
“I need two months,” said New York City’s Chokshi, adding that a longer ramp-up time would let the city secure vaccination sites, schedule staffing and make other plans — such as whether to rely on existing infrastructure, or in the case of a supply influx, set up mega-sites.
While two months sounds like an ambitious target, participants argued that vaccine makers know their production schedules for several months in advance. Those manufacturing plans guide pharmaceutical companies when they strike deals with governments to supply hundreds of millions of shots, and state and local officials should also have access to that information.
Slower vaccination of racial and ethnic minorities.
The coronavirus pandemic has shone a bright light on long-existing health disparities and societal gaps: Black, Native American and Latino people are more likely to become severely ill, hospitalized and die from the coronavirus than white counterparts. But Black adults in particular are still hesitant to get the vaccine. In studies presented to an expert CDC panel last year, respondents cited historical mistreatment from the health care system and concerns that elected officials are not looking out for Black Americans.
That combined with decades of diminished public health resources in communities of color has already contributed to distribution inequity: White women have outpaced every other group so far for getting vaccinated, according to federal data, though many people did not record race and ethnicity.
“One of the biggest and most devastating lessons for us in our attempt to reach high throughput … we were pushing a large amount through mass vaccination clinics,” said Oregon Health Agency Director Rachael Banks. The state tried to be inclusive, “but [it] simply was not enough.”
That is common when governments prioritize speed, said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. “If we’re going to continue being efficient, then we need to understand that when we start seeing equity data is not going to look very good. Efficiency doesn’t really generally lead to a lot of equity: It’s kind of a first-come-first-serve, and we know who tends to do best in those situations.”
Confusing data about vaccination rates.
Hackathon participants described data frustrations with the federal government. For starters, officials complained that the Centers for Disease Control and Prevention’s vaccine tracker, which publishes supply and use, tells a misleading story about the amount of shots states have received versus how many are administered.
Every state looks like they have failed to distribute as much as 30 to 40 percent of the doses they’ve received when the truth is more complex, said Florida Director of Emergency Management Jared Moskowitz. States are typically holding back some stock for second shots.
“That increases the anger with people; they think somehow we’re not getting all our doses out fast enough, even though we are blowing through our weekly allocations,” said Moskowitz. “Messaging correctly from the CDC … would help decrease some of the anger so it doesn’t look like states are just sitting on doses.”
That may be complicated: White House Covid-19 adviser Andy Slavitt recently urged states not to stockpile supply for second doses. But the officials said that’s not practical unless they have a better picture of future supplies.
Too much reliance on online and digital tools.
It’s not enough to set up vaccination sites in underserved areas or communities of color. Florida did that, said Moskowitz — and it still did not go to plan.
“Because there was a rush to put shot in arms, everybody went digital” to fill vaccination slots, he said. “When you go digital, people will drive hours into a neighborhood if they can get that appointment, and that is what’s happening.”
Seeing the trend play out, Florida came up with a plan to “take the technology out of it,” said Moskowitz. The state has since partnered with faith-based institutions and set up sites at churches. Moskowitz is also considering vouchers to hand out to people in need as a non-tech version of planning for vaccination sites.
Bridging the digital divide includes messaging for vaccination sites and information that comes offline, such as flyers about availability and outreach through public transportation and other strategic areas, said state and city leaders. It could be as simple as posters on the sides of buses that say we have “a plan for reopening” atop an image of a syringe, said Fresno County Interim Health Officer Rais Vohra.
Lack of funding and logistical information from the federal government.
All the participants agreed they need more funding to roll out vaccination campaigns, set up distribution sites and employ thousands of people in the process. One reason is that unlike the federal government, states are not able to deficit spend; they can only tap funds they already have. But state tax revenues have fallen sharply because of the economic downturn, and financial assistance from the federal government has been slow coming.
“It’s been really challenging for us to just reach out to different communities,” said Vohra. “Having more resources related to distribution is certainly welcome. It would have helped a long time ago.”
Vohra added that local officials need logistical information as early as possible for new vaccines coming down the pipeline, particularly the single-dose Johnson & Johnson Covid vaccine that the Food and Drug Administration is expected to authorize for use soon. Its single-shot regimen and easier refrigeration requirements mean it could be a game changer for public health officials trying to vaccinate hard-to-reach groups, ensuring they are fully vaccinated without needing to schedule and keep a second appointment. But officials need to know now more details about its refrigeration requirements and other protocols.
“I know that it hasn’t been approved by the FDA, so that does sound premature, but we really need that information now so that we can start planning for it so that the day that it becomes available to us, we are ready to go with all of the logistics and operational details that are needed for that vaccine — and for every other vaccine coming into the future,” said Vohra.
Sluggish national rollout for nursing homes.
Scientists agreed early on that nursing home residents, who have accounted for roughly a quarter of U.S. coronavirus deaths, should be among the first to receive Covid-19 vaccines. But by January, many states complained about the slow pace of a federal program to distribute those key shots through partnerships with national pharmacy chains CVS and Walgreens.
The only state to forgo the federal program, West Virginia, finished nursing home vaccinations within about two weeks. The national chain pharmacies were slower, taking until late January to finish the first round of shots in the facilities amid scheduling complexities and the slog of planning ahead with each home to gain residents’ consent and project supply needs.
West Virginia’s early decision to strike out on its own with community pharmacies was part of “MacGyver-like” planning, said Health Commissioner and State Health Officer Ayne Amjad, describing a style of use-what-you-have solutions. “You take risks, but you have to know what’s right for your state.”
Despite West Virginia’s early success in administering shots to older citizens, Amjad says her state is readying for tough work ahead with hard-to-reach and skeptical people throughout the state — efforts that won’t be possible without additional federal support.
“No one wants to come to West Virginia; the pay is low, we lack resources. … But you make do with what you have,” Amjad said about the scope of challenges ahead.
PART 2: FIVE POLICY HACKS TO IMPROVE VACCINATION
In their states and cities, POLITICO’s policy hackers pioneered a number of innovative approaches to overcoming the barriers to vaccination. At the same time, they were clear about the limits of what they could accomplish on their own and what they need federal officials to provide — primarily, clear, well-calibrated public messaging.
Here are five things they identified that could go a long way toward fixing some of the early problems with the U.S. vaccination effort.
1. Start a federal media campaign to combat vaccine hesitancy now.
Local health care leaders want to see more leadership on vaccine confidence issues from Washington. After all, said Shereef Elnahal, CEO of University Hospital in Newark and former health commissioner for New Jersey, “the federal government has the advantage of scale and funding.”
What state and local officials really need is for the federal government to develop a national messaging toolkit, much like it did with the swine flu outbreak in 2009, that can be adapted and applied to different communities, said Greg Holzman, Montana state medical officer, who worked for Michigan during that pandemic.
“We can take that backbone, and then adapt it for our environment,” said Holzman.
That strategy could also draw from broad swathes of data supplied by states and localities that may suggest trends for outreach and trust, said Elnahal.
“If the CDC or different body were to invest in building an evidence basis for how to combat hesitancy, especially in communities of color … [they could assess] whatever statistical data is associated with strategies that have worked” and develop a national toolkit, he said.
That would save critical time at the local level, argued Elnahal, whose city of Newark, which is majority Black and Latino, has struggled with Covid surges that at times far outpaced the rest of the state. “We tried strategies that didn’t work in the beginning.”
2. Microtarget minority communities.
Early lags in getting historically underserved people vaccinated led Oregon to hash out culturally specific approaches and public health needs in the vaccination drive, such as targeted work with faith leaders and respected officials of Native American tribes.
“It’s not just about vaccines. There’s an entire historical context of governmental public health, the medical system and the medical distrust that folks have,” said Oregon’s Banks. “We’re dealing with whole communities, whole populations who want to be addressed in the whole vitality of their culture.”
There is a model for community trust in the eight Montana tribes, many of which live across seven reservations in the state, said Montana’s Holzman. The autonomous reservations have done a “fantastic job” with vaccination so far in large part because “working in communities, getting out and getting the information to the right people has made all the difference in the world.”
For Black communities, it is about reestablishing trust that’s been eroded by decades of neglect, said Elnahal. “There’s this concept that, look: You were able to generate the will, motivation and funding to develop a vaccine for this disease within a year, and yet we’ve been dealing with public health issues in our community for generations that you still have yet to solve?”
3. Redirect vaccine messages to focus on preventing hospitalization and death.
Officials are excited about the single-dose Johnson & Johnson vaccine, because it will be far easier to distribute. But while the J&J vaccine is super effective at preventing hospitalization and death, it is not as broadly effective against moderate disease as the Pfizer/BioNTech and Moderna shots that hit the market earlier and set an incredibly high bar. But as a tool to help halt the spread of the pandemic, participants said that it will be very valuable — as long as officials can prevent the public from getting the idea that it’s inferior to the alternatives.
The message that needs to come from public health officials at all levels, the hackers said, is that the goal of getting vaccinated is to prevent severe illness, not all illness.
“I wish people had a better understanding of its usefulness in preventing severe illness and death,” said Banks.
What’s more, news that variants of the coronavirus are spreading may raise public concern about the effectiveness of the vaccines — bringing questions about whether people will eventually need booster shots or new, targeted vaccines. In the short run, though, the more people are vaccinated with the existing vaccines, the less of a chance for further virus mutations.
“I think that’s going to be a tremendous logistical challenge,” said Angela Rasmussen, a virologist at Georgetown University Medical Center. “It’s also going to be very difficult to communicate to people why they should keep taking these vaccines.”
4. Partner with religious and community leaders.
Most state and local leaders have recognized that relying on community leaders builds confidence and makes vaccination easier for many people, particularly those marginalized from the health care system.
Health officials have long relied on trust between patients and providers when it comes to major medical decisions and other public health measures such as childhood vaccinations. But many underserved people do not have a trusted doctor or pharmacist; for them, government leaders need to appeal to community, family and faith leaders.
“We have to almost make our vaccine messaging more contagious than the virus itself and turn all of those people into vaccine ambassadors,” said New York City’s Chokshi. “So that whoever someone is going to turn to, who they trust to make a decision like this one, they’ll have the information that they need.”
But those kinds of efforts take an influx of state and local funding, said Plescia, because of needs to contract with local groups and hire more community-based workers for outreach. Those agreements with community-based organizations to help stoke confidence “are perhaps more important than PSAs and stuff you might see on TV.”
5. Use mobile vans to go to the people you want to vaccinate.
In the early stages, motivated residents have been willing to travel long distances to get vaccinated, but as the campaign shifts to focus more on hard-to-reach or reluctant communities, it will likely be more effective to bring the vaccine to people instead. Several officials discussed putting vaccines on the move, especially in the warmer months. Mobile vans could be a relatively easy option, especially with certain shots such as the refrigerated J&J vaccine rather than ultra-cold Pfizer shots.
Vans could also be a way of vaccinating homebound populations that some, such as Chokshi, say they have struggled to reach in the early months of vaccination. They could also be helpful to reach people at their workplaces, particularly frontline workers in public-facing jobs, or people experiencing homelessness.
As vaccine supplies grow, health officials are looking forward to shifting away from mass vaccination sites and leaning more on federal quality health centers and community clinics that people in the nearby areas trust.
“We started out and we really pumped a lot of vaccine to high throughput sites,” said Oregon’s Banks. “And now we’re saying that we need a varied distribution model, whether it’s mobile clinics, [federally qualified health centers] or to address the digital divide.”
LEARNING AS THEY GO
As the historic vaccination push continues nationwide, state and city leaders are learning as they go about the best methods to reach the country’s varied and diverse populations. Some are looking to others’ examples; others are learning from their own mistakes.
“I can tell you that every single day I am frustrated, my hair is getting grayer, but I always have to stop and look back and think about how we actually have done a lot, and a lot has been pretty impressive,” said Holzman.
The policy hackers who joined POLITICO were optimistic about outreach and community initiatives, but are bracing for even more challenges ahead both in convincing people to get vaccinated and securing steady supplies as the pandemic moves deeper into its second year.
“I think a lot of this could have been made easier if there had been more transparency and a more coherent plan from the federal government,” said Rasmussen. “I’m really encouraged, actually, hearing what everybody has done. It is really remarkable work, to do the best they can under incredibly difficult circumstances.”