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April 21, 2021 – Four months into the largest vaccination campaign in U.S. history, roughly half of all adult Americans have received at least one shot against COVID-19 and the nation is vaccinating more than 3 million people daily.
But those nationwide averages belie looming standstills in pockets of the country where people aren’t showing up for appointments and vaccines are piling up in refrigerators.
“We’ve harvested the low-hanging fruit, now we’ve got to do the hard work,” said Dr. William Schaffner, professor of preventive medicine at the Vanderbilt University School of Medicine. “For every incremental increase in the number of people vaccinated, it’s going to get harder and harder.”
Vaccine supplies are beginning to exceed demand in some places, particularly in pockets of the Midwest, West and South, prompting some public health officials to reallocate shots within their borders and develop new strategies for reaching people who are leery about getting vaccinated.
Current data from the federal Centers for Disease Control and Prevention indicates that New Hampshire has the highest per capita vaccination rate, followed by Connecticut, New Mexico, Vermont, Maine, Massachusetts, Rhode Island, the District of Columbia, South Dakota and New Jersey. At the bottom of the list is Alabama, preceded by Mississippi, Georgia, Tennessee, Arkansas, Louisiana, Idaho, Indiana, Wyoming and South Carolina.
In Alabama, Assistant State Health Officer Dr. Karen Landers said health officials in her state aren’t paying attention to where they fall in the CDC’s national rankings.
“We believe the wax and wane in terms of our overall demand for the vaccine in Alabama is really temporary,” she said. Tornadoes in the northern part of the state and spring breaks at universities and public schools are part of the cause for the most recent slowdowns, she said. Overall, limited transportation in rural areas and many residents’ need for more information about the vaccines are responsible for the state’s slower uptake, she said.
Landers noted demand for shots remains high in Alabama’s urban centers, including Birmingham, Montgomery and Mobile, where the National Guard is helping deliver vaccines. She said the state fully expects to use all the vaccines it has been allocated by the federal government.
“It’s just going to take time,” she said.
But in Tennessee, where demand is also lagging, Schaffner said it’s going to take more than time and hard work to vaccinate enough Tennesseans to reach herd immunity—a proportion of the population, estimated at about 80%, that most scientists agree would leave the coronavirus with so few hosts it would cease to be a threat.
“Conservative state and local political leaders are going to have to stand up and tell their constituencies that it’s the right thing to do for their families and their communities,” he said.
“So far, that’s not happening.”
Many of the places where demand is ebbing and vaccine hesitancy is high are the same areas where people are eschewing masks and social distancing, a confluence that epidemiologists worry could foment new COVID-19 outbreaks.
In Michigan, epidemiologist and former Detroit Health Department Director Dr. Abdul El-Sayed said that’s already happening. Michigan’s worst-in-the-nation spike in new COVID-19 cases and hospitalizations is being driven by high transmission rates in conservative communities, he said.
“We’re in a situation where unless we’re able to get a handle on the highest-risk activities, including dining, gyms and indoor sports, it’s going to be hard to control the outbreaks. We definitely need a lockdown right now,” he said.
Last week, those outbreaks led Democratic Gov. Gretchen Whitmer to ask the Biden administration to reallocate vaccines to her state. The administration turned down her request, with CDC Director Dr. Rochelle Walensky saying that vaccinating more people was not an effective way to quell the state’s COVID-19 surge because the shots take two to six weeks to become fully effective.
Whitmer initially balked at enacting new restrictions to counter the uptick, saying the state already had among the nation’s strongest public health protocols. The problem, she told the Detroit Free Press, was the spread of a more contagious COVID-19 variant and pandemic fatigue. The latter caused Michiganders to stop wearing masks and to ignore other recommended precautions.
But in an April 11 interview with CBS on Face the Nation, Whitmer blamed the majority-Republican state legislature for limiting her powers to control the virus.
Claire Hannan, executive director of the Association of Immunization Managers, which represents state, territorial and metropolitan public health immunization officials, said she agreed with the administration’s choice not to reallocate vaccines—at least for now. “I do think that we need to carefully watch the supply and demand data and prepare for a possible reallocation among states in the future,” she said. “But we don’t want to change what’s working right now.
“It’s taken us a long time to work the flaws out of all this and build a system of getting shots out efficiently and providing multiple ways for people to access the vaccine. We should take advantage of that momentum and get as many people vaccinated as possible, particularly young people,” she said.
In the meantime, Michael Fraser, executive director of the Association of State and Territorial Health Officials, said some members of his organization are discussing ways for states that are taking longer to administer vaccines to temporarily allocate some of their supplies to states that need it.
That occurred at the beginning of the vaccine campaign, he said, when Maryland and Virginia gave vaccines to the District of Columbia. At the time, supplies were running short in the District, in part because Maryland and Virginia residents who work in D.C. were going there to get their shots. “It’s unclear whether any states would be willing to do that voluntarily right now,” Fraser said.
“Any rebalancing of vaccine supplies,” he argued, “needs to be part of a national plan, not just based on state-to-state relationships. We don’t want to repeat the PPE situation where states were making deals with manufacturers and competing against each other.”
Dr. Leana Wen, an emergency physician and visiting professor of health policy and management at George Washington University’s Milken School of Public Health, echoed those comments.
“The definition of equity, which the Biden administration is always promoting, is that you provide public health resources to areas that are most vulnerable, hardest-hit. You can’t say allocating based simply on population is the equitable thing to do. If you’re going to be for equity, you have to be for it the whole way,” she said.
Leaders and Laggards
When COVID-19 vaccine campaigns began in mid-December, smaller states including Alaska, followed by West Virginia, South Dakota, Maine, New Mexico and North Dakota, raced ahead of the pack, quickly vaccinating a higher percentage of their populations.
In large part, their success was the result of centralizing vaccine distribution rather than delegating to counties and towns.
Now, many states are rethinking their initial strategies, finding new ways to persuade reluctant residents to roll up their sleeves while maintaining high-volume vaccination sites in large urban areas where demand is high.
“I don’t like to rank states,” said Hannan of the immunization managers association, because the challenges are different in different places. For some states, particularly those with large rural populations and more vaccine hesitancy, the process will take more time and effort, she said.
State vaccination rates are also affected by federal vaccination programs, including highly successful Department of Veterans Affairs and Indian Health Service campaigns. In Hawaii, New Mexico and Oklahoma, for example, at least 15% of all vaccines have been administered by the federal government, while in most other states, federal programs account for less than 5% of all shots.
While many of the federal government’s more than 400 mass vaccination sites are operating at full speed, reduced demand in some parts of the country will require more granular distribution approaches, including door-to-door vaccinations and multiple pop-up and mobile vaccination sites, she said.
And instead of waiting for people to sign up for appointments online or by phone, health departments may need to start proactively calling residents who haven’t received a shot, said Adriane Casalotti, chief of government and public affairs at the National Association of County and City Health Officials.
That’s already happening in Chicago with great success, Casalotti said. In fact, in some parts of the city where demand had dropped off, phone calls brought in so many residents that the state agreed to transfer some of its vaccines from southern counties to replenish Chicago’s supplies.
On Monday, everyone 16 and older in all 50 states became eligible to get a shot. That means states need to act quickly to vaccinate as many young people as possible, Hannan said, because recent COVID-19 outbreaks have primarily been caused by transmission of the virus among young adults.
But persuading young people to roll up their sleeves may not be easy. According to ongoing surveys by San Francisco-based nonprofit health care research organization the Kaiser Family Foundation, 25% of people 18 to 29 and 18% of people 30 to 49 say they want to wait and see how the vaccine is working for others before they get a shot. That compares with only 7% of people 65 and older.
States also will have to work harder to persuade Republicans. According to Kaiser, 29% of Republicans say they definitely do not want a shot. That compares with only 5% of Democrats and 9% of Independents who say they won’t get vaccinated.
“Historically, vaccines have not been political. They’ve always been supported by both parties,” Hannan said. “We may be conflating politics with conservative attitudes in certain parts of the country where fundamentally people have questions about the vaccines and want to make sure they’re safe and effective. That’s understandable. We really need to listen to them and address their concerns.”
Stateline, an initiative of The Pew Charitable Trusts provides daily reporting and analysis on trends in state policy. Stateline content is published daily at pewtrusts.org/stateline.