Local public health experts refocus, with some fumbles, on addressing COVID-19 access issues

Intelligencer Journal - 5/23/2021

Over the past three weeks, Pennsylvania providers have increasingly requested fewer doses of COVID-19 vaccines than federally allocated, just as the state is ramping up its efforts to get shots into reluctant arms.

Requests for vaccine doses have dropped 74% from April 26 to May 10, according to the latest data available from the Pennsylvania Department of Health.

Eroding demand — experts say — could hamper vaccination campaigns targeting difficult-to-reach communities, such as the one underway in Lancaster County.

“This just tells you that you’re hitting a wall; that the people who wanted to be vaccinated are largely vaccinated now,” said Dr. Amesh Adalja, an infectious diseases physician and senior scholar at the Johns Hopkins Center for Health Security.

With the crush of those desperate and willing to get a COVID-19 vaccine relegated to the not-so-distant past, health officials say the real work begins now.

“In general, what we’re finding is that it’s getting harder and harder to find people to get vaccinated,” Adalja said.

This has real-world consequences as vaccines have been touted as the way to return to pre-pandemic life.

“It’s our shot at really bringing the pandemic to an end,” said Dr. Mark Goedecker, vice president and regional medical director for WellSpan Health’s central region.

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‘We can’t make assumptions’

Roughly 37% of Americans are fully vaccinated against COVID-19, according to Centers for Disease Control and Prevention (CDC) data.

Pennsylvania falls in the middle of the pack, with 20 states having a greater percentage of its population fully vaccinated.

As of Monday, about 39% of Pennsylvanians were fully vaccinated.

In Lancaster County, more than 197,000 individuals — or roughly 36% of the county’s population — were fully protected against the pathogen, as of Monday.

Achieving herd immunity has long been the goal for eradicating the novel coronavirus.

Herd immunity is when a sufficient number of people are protected from a disease — either through infection or vaccination — that its spread is significantly curtailed or even stopped in the wider community. It’s what led Gov. Tom Wolf, while lifting other mitigations, to keep his face mask order in place for unvaccinated individuals until 70% of Pennsylvania adults are fully vaccinated.

Initially — when vaccines were still an unrealized hope — scientists and public health experts had speculated, to be protective, that 60%-to-70% or more of the population would need to be inoculated.

Now — with daily vaccination rates dramatically slipping — reaching herd immunity increasingly appears unlikely because of emerging variants and a stubborn hesitancy with the vaccines.

“We’ve hit a lot of the big areas with our major vaccination sites and now we’ve got to take the vaccine to the people,” said Goedecker, with WellSpan.

Goedecker added, “We can’t make assumptions about why people aren’t getting the vaccine. That’s the biggest mistake we can make.”

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‘It’ll add up’

Roughly six weeks ago, a countywide coalition emerged to address COVID-19 vaccine access and equity.

Facilitated by Alice Yoder, executive director of Community Health at Penn Medicine Lancaster General Health, the coalition is comprised of about 30 members with various ties to vulnerable communities.

Many of these “trusted partners” — as Yoder calls them — have already held a number of pop-up clinics aimed at vaccinating Lancaster County’s rural population, refugees and the homeless, among others. The idea behind these pop-ups is to vaccinate individuals where they are, rather than require they go to a mass vaccination site.

“A one-size-fits-all campaign doesn’t really fit all,” said Rachel Helwig, development and communications coordinator for Church World Service Lancaster, which provides support to refugees, immigrants and asylum seekers.

With large swaths of the county still unvaccinated, and fewer clamoring for a shot, the days of inoculating hundreds or thousands in a single setting may soon be in the rearview mirror.

“It may not be 1,000 people a day,” Yoder said. “It could be those 10s or 50s, but it’ll add up.”

But even these more targeted efforts have not been without missteps.

A recent clinic directed at Latinos in Lancaster, for example, didn’t have Spanish speakers to field phone appointments. And many of these clinics have occurred during work hours, a challenge for low-wage workers who are least likely to have paid time off and often have less schedule predictability and flexibility.

“I think we could have and should have done a better job,” said Dr. Cherise Hamblin, founder of Patients R Waiting, a nonprofit organization focused on eliminating health disparities by increasing diversity in medicine.

Hamblin, an OB-GYN physician at Lancaster General Hospital, added, “The hard work, we’ve known that it was needed from the very beginning.”

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‘A steady decline’

Early in the vaccine rollout when demand outstripped supply, it was not uncommon for patients to travel out of the county for an appointment or seek help from vaccine hunters.

Those days are gone.

Although designed to accommodate 6,000 people a day, the Lancaster County Community Vaccination Center at the former Bon-Ton in Park City Center hit its apex on April 20, with 5,834 vaccinations.

Brett Marcy, a spokesman for the mass vaccination site, told LNP | LancasterOnline in an email that “Following that peak, we began to see a steady decline in first-dose vaccine demand” and the average number of daily vaccines is roughly half of initial projections. In response to waning interest, the site has discontinued Sunday appointments and curbed its operating hours.

This isn’t just a Lancaster County phenomenon. Demand has tumbled across Pennsylvania and the nation.

Nationally, the number of daily doses administered peaked on April 1, with 4.2 million Americans rolling up a sleeve. Since then, the seven-day rolling average has plummeted from 3.08 million to 187, 762 on Tuesday.

In Pennsylvania, vaccine providers the week of May 10 requested 25% of the state’s weekly allocation, or 149,220 doses out of the nearly 600,000 available, state data shows. The previous week, providers requested nearly 400,000 doses out of the more than 600,000 Pennsylvania was allocated.

April 26 marked the turning point in Pennsylvania after which vaccine requests began dropping.

With providers no longer required to administer 80% of their allotted vaccine within seven days and fewer arms to jab, it is likely the vaccine doses delivered last week does not represent the existing supply in Pennsylvania.

The decreased in demand — local health care leaders say — indicates a real need to pivot.

“It says we thought we could just open the doors and people would just come in,” Hamblin said. “That’s the reason why the lag is there.”

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‘It’s important to be nimble’

Vaccine hesitancy is a complex issue with no single motive driving reluctance.

Among the reasons are a distrust of the government and health organizations; apprehensions around efficacy and safety; personal freedom and side effect worries.

And — in the case of the Johnson & Johnson/Janssen vaccine — some harbor moral concerns about its development, as the J&J vaccine was produced, in part, using cell lines derived from an aborted fetus.

Jon Carlson, lead pastor of the Forest Hills Mennonite Church, said he urged parishioners to consult their doctor and estimates 70% of his Leola congregation are vaccinated.

“I think some of it’s that they’re not always aware how complicated medicine is,” said Carlson, who recently spoke during a United Way of Lancaster County panel on access and equity.

The J&J vaccine has been an attractive choice for targeting difficult-to-reach populations such as the homeless, undocumented and Plain communities. This is because the single-dose vaccine requires rallying these communities only once.

So, the federal suspension last month presented an unwanted setback to the coalition.

“It’s important to be nimble,” said Yoder, facilitator of the COVID-19 Access and Equity Coalition. “What’s working now may not work in two weeks.”

It remains unclear how widely the J&J vaccine will be deployed in Lancaster County. But Yoder said the one-dose vaccine could still be an integral part in the coalition’s efforts.

When offered a choice of vaccines, in two hours at a recent clinic in Peach Bottom, half of the patients opted for the J&J vaccine, Yoder said.

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‘Inequities have exited for decades’

Strategies to address vaccine hesitancy have also turned to providing incentives.

Those incentives have included everything from a free beer and a free ride, to college to a chance to win $1 million, to track time behind the pace car on Alabama’s Talladega Superspeedway. Locally, for example, Lancaster-based Woodstream Corp. is giving a day off and $300 to employees who get vaccinated.

For all the hand-wringing over the disinclined — Yoder and other community leaders contend — vaccine access is as big an issue as hesitancy.

“Inequities have existed for decades and generations relative to communities of color,” said Blanding Watson, Lancaster NAACP president. “I think that people of color always get the tail end of things when it comes to health care.”

COVID-19 laid bare many of these inequities with communities of color having been disproportionately impacted by the pandemic.

Blacks and Latinos have had some of the highest COVID-19 morbidity and mortality rates in the U.S., the likely result of social determinants of health, generally recognized as the environmental conditions where people live, work and play.

Watson added, “I think it’s hesitancy and access. I think it’s both.”

Yoder, with the COVID-19 Access and Equity Coalition, could not agree more.

A self-described optimist, Yoder said she’s encouraged despite the late nights because the effort — which will likely continue through the summer — does not rely on a single strategy.

“We’re in it for the long haul,” Yoder said. “If we don’t achieve it in the next month, we’ll just keep on going.”

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Crédito: NICOLE C. BRAMBILA | Staff Writer