Getting Shots Into Arms: The Race to Vaccinate Against COVID-19

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson. On this episode, the urgent campaign to vaccinate the nation against the COVID-19 virus, managing complicated logistics and storage requirements while setting expectations of those waiting for their shots.

DR. THOMAS DOBBS:
It's kind of a two-edged sword, right? We are super excited about the vaccine, but it causes anxiety when people can't get it. So, we need to make sure we balance that interest without causing unnecessary anxiety within individuals.

CLAIRE HANNAN:
I think we're all waiting for production to scale up. But I think production has been steady, so I think it makes sense to take doses and get them out into the community.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, reviewing the state of the nation's COVID-19 vaccination campaign and the early lessons from a drive that, believe it or not, started only about five weeks ago.

Two experts join us today to discuss progress and problems encountered already, offering thoughts about the way forward as the majority of Americans wait for their vaccinations.

Dr. Thomas Dobbs is the state health officer leading the Mississippi state department of health, his team working hard to manage expectations about the vaccine rollout. He's along shortly.

First, Claire Hannan, executive director of the Association of Immunization Managers, who hopes the work to crush the virus will ultimately be viewed as the greatest public health effort of our generation.

HANNAN:
I think I would like to start with things that are going well, and, certainly, getting over 9 million doses into arms is a great achievement. And I think what has gone well is our efforts to really build a robust infrastructure of providers.

So, we've enrolled tens of thousands of private providers to agree to give the COVID vaccine. They've received education, they've been trained, their storage capacity has been assessed, their patient population has been assessed, so that groundwork's been done. That infrastructure is there.

We've especially focused on the hospitals for Phase 1A, and shipment to the hospitals has been ongoing. The vaccine is shipping well, the ordering system's working. So, these things are good. They're working, they're in place.

We do see, you know, that vaccine uptake is not really where we'd want. We definitely want to have more vaccines going into arms at a faster rate.

JOHNSON:
So, how about areas where you think we could improve?

HANNAN:
So, there's three areas that we need to look at and make sure we're doing everything we can to improve.

So, the first one is hospitals and, you know, getting vaccines—that was always the plan, was to get vaccine to hospitals because that's where healthcare workers are. And offering them vaccine in their place of work, making it easy for them, that's probably the best way for them to get it. So, that was the plan. So, the question is what's taking the hospitals longer? Is it taking them longer to get vaccine out? Is this a capacity issue with hospitals? Do they need more time? Are they just taking a more cautious deliberative approach?

Obviously, it's very important they follow the protocols, the throughput of the clinics observe for 15 minutes and do all of that. It's a delicate vaccine, making sure that they mix it properly, all of that is really important. So, you know, is it taking them longer to do that or is it potentially hesitancy?

And I think there are just a number of things going on there. And a lot of questions and healthcare workers saying, "You know, I want to get the vaccine maybe next week, maybe that's happening." So, looking at that, helping hospitals to be more efficient.

The second thing is all the other providers outside of hospitals—so, mostly local health departments who are focused on getting healthcare workers vaccinated. And I think that percentage of doses they have used is probably a little higher than hospitals right now, but it's still not where we would want it to be. So, again, what can we do to improve that? You know, scheduling, what are the issues? Is it uptake? And so, I think we're really looking at that and we need to discuss these thoroughly.

The third area is the long-term care facility program and long-term care facilities are a part of Phase 1A, but it's a separate federal program partnership with CVS and Walgreens to vaccinate in long-term care facilities. And it looks like they are vaccinated or are they have vaccinated about 30% of the doses they have received.

So, we definitely want that to get higher. And I think that will improve. CVS and Walgreens are really only just hitting the ground running this week, but we need to support them in any way that we can and find out what kind of challenges they're having.

It's very difficult to vaccinate in long-term care facilities. You know, people are not mobile. You need to go room to room. They may take some time, they may have questions, they may not be able to read or understand that consent form. So, there may be a lot of things going on there.

So, with Phase 1A, you know, there are a lot of things going well. Obviously we want to get more quick about how we get doses into arms—we don't want doses to sit on the shelf—but we need to be deliberative about how we do that.

JOHNSON:
Have you made note of any best practices at this stage of the campaign? Anything happening in the field that's worth noting here?

HANNAN:
Well, sure. I mean, I think that's the million dollar question, right, is how are some of these states that have higher percentages of doses distributed or administered, how are they doing that?

And, you know, looking in the rural states, looking in the rural areas, I think they are using their plan of spreading the vaccine to providers. They have really strong relationships with providers.

They're able to tell their providers, you know, exactly how many doses they're going to get and when they're going to get their next set of doses, so the providers aren't holding on to doses. They're trusting they're going to get more doses, they know when it's coming. Smaller states can do that. Some of them are redistributing, so they're breaking down these larger packages of 975 doses, you know, and I think that's a good thing, these strong relationships with providers, certainly a best practice.

But, that strategy might not work in larger states, so I think it is specific to areas. I think what will work is really guided by the state itself and how they're structured. Some are more centralized or decentralized, you know, some have a smaller number of providers. So, some of the things that are working in the rural states might not work in larger states.

And we're also looking at what might be working in the larger states, just trying to get that out. And I think it really is around getting the supply to the place where the demand is, and that might be more centrally coordinated through public health. So, in other words, having a larger scale of clinic where you can vaccinate all day, scheduling appointments, vaccinating all day—different from sending it to multiple hospital sites.

JOHNSON:
Let's talk about the idea of using all of the doses as they are delivered rather than holding back half of them for the required booster shots. Is that a good strategy given the state of vaccine production at this point in the effort?

HANNAN:
Well, I think for that strategy to work, it's really critical to have that confidence in production. And, you know, I think that the production has been steady. It has not increased, you know—I think we're all waiting for production to scale up—but I think production has been steady. So, I think it makes sense to take doses and get them out into the community.

I mean, if you have doses that are being sent out, let's say, and you're sitting another set of doses on the shelf for 21 or 28 days, and then the doses that you sent out aren't being used at 100% capacity, then you have 100% of those doses sitting on the shelf, now for 28 days, even longer because your first dose is taking longer to get out.

So, I think it just makes sense—if production is steady, then you get all of the doses out. And we've seen that shipping within 24 hours is successful. We've seen the ordering is efficiently working. So, get all the doses out and have providers order their second dose, you know, 24 hours before they need it.

And I think that it's confusing to states to get four allocations—to get a first dose Moderna, a first dose Pfizer, a second dose Moderna, a second dose Pfizer—and that especially gets confusing now when you have first dose administration being spread over a week period, but all those second doses are still sitting on the shelf.

So, I think it makes sense. I think it's good. It is risky. You do need production to stay stable, but I think we are there with production.

JOHNSON:
How are we doing when it comes to reaching communities of color, addressing the health equity issues involved with this pandemic?

HANNAN:
Health equity is a really big challenge, and I think that is such a difficult challenge in a time when you have limited supply of vaccine and in a time when you're in an emergency situation where you have people dying.

What I'm hearing anecdotally, and I think what we saw through polls and surveys before the vaccine was authorized, was that there was a much higher acceptance in whites and a lower acceptance, a lower trust factor in confidence in the vaccine in minorities. And I think we're seeing that play out to some extent. I don't know that we have perfect data on that, but I think we're seeing that play out with healthcare workers.

And so, we have to be really vigilant in our efforts to get vaccine into arms that we don't skip the step of building trust in communities of color and making sure that we're making every opportunity for equal access to the vaccine. And so, you know, we have to be very vigilant about that. And I think it's hard, it's challenging when you're doing large clinics.

So, we need to make sure, as we're doing large clinics, we're locating them in places that are accessible. I hope that we will get to the point where we can spread the vaccine so widely that it's accessible everywhere.

Obviously, we have made the commitment to make it affordable. So, that's not an issue. But building the confidence and the trust in these communities—and I think right now we're about to launch a large scale communications campaign. I think states are engaging in communities and launching a communications campaign of their own.

But we don't exactly know, you know, exactly the data on the uptake, and we don't exactly know every issue and every concern. So, I think it's just really important to push out messages on the safety and the effectiveness of the vaccine to build that trust and to remain vigilant about making the vaccine accessible to healthcare workers.

We are not just going to move on if we haven't vaccinated every healthcare worker. That opportunity is still there, and we still want to promote that, and we still want healthcare workers to getting the vaccine. And as we expand out, we still want everyone to be getting the vaccine. Eventually, we want all Americans that want the vaccine to get it.

JOHNSON:
It is funding is still a concern?

HANNAN:
I think the funding has been one of the critical challenges that still remains to be addressed. So, yes, Congress did just pass funding in the last several weeks, but it hasn't reached the states yet. We're hearing that it will reach the states this week.

That's something critical that states and local health agencies need. So, you know, we've basically built this infrastructure, enrolled all these providers, submitted all these plans, built communication plans—a lot of that, you know, were wish list because they weren't adequately funded and states and local health agencies critically need that funding.

It's difficult to take funding and to scale up staffing, and IT, and you know, communications, and hotlines, and hire vaccinators' contract with employees. It's difficult to do that at the flip of a switch. So, even though funding is expected this week, it will take some time. That funding should have been out six or eight months ago—I mean, at least three or four months ago—and we shouldn't have had to spend precious and valuable time and energy fighting for that funding.

Of course funding is needed, of course it's needed. We don't have a publicly financed vaccine or healthcare infrastructure in this country. We don't ordinarily just give vaccines for free to adults.

We have private insurance, we have private providers, and, you know, having to build that infrastructure and having to build that data—it's costly. And now, when you're looking at hiring vaccinators and getting sites and security and traffic and planning—that all costs.

So, to think that, you know, states and local health agencies—even hospitals, others—would be able to give vaccine and then apply for reimbursement to insurers, to think that we could finance a government sponsored campaign for all Americans that way—that was very naive and we're paying the price for that. And we need to get that funding out as quickly as possible so that we can scale up. Staffing is the most critical need right now for state and local health agencies.

JOHNSON:
Despite all of the challenges, how would you characterize the vaccination campaign so far?

HANNAN:
I think it's incredible, and I've been working in immunization for 20 years. And if you had told me a year ago that we would be able to stand up the infrastructure necessary to give a vaccine to everyone in a year, I would have said, "Impossible!"

And then, to throw in you're in the middle of a public health emergency, and you're not only building that infrastructure but you're also dealing with the virus itself. And then, to throw in on top of that, you've got a contentious election with a divided country. You know, I think that the system that we have built, the groundwork we have laid, is simply incredible.

And I understand that, you know, we can't get vaccine into arms fast enough. You know, we just can't, because there are people dying. But, it's incredible what we've built, and we will get vaccine into arms more quickly each week, and we are continuing and will continue to make progress. And, you know, I think this vaccine program will eventually get us out of this pandemic.

JOHNSON:
As we heard at the top of the podcast, Dr. Thomas Dobbs is thinking about the best way to keep people in Mississippi interested in the COVID-19 vaccine while they wait their turn to get the shot. It's just one of several vaccine-related challenges he's managing as state health officer for the Mississippi state department of health.

DOBBS:
You know, it's been a bit slower than we would have wanted. One of the things that is important to keep in mind is the visibility of the vaccine coming your way. And this is something we are struggling with right now, is scheduling appointments in the future, right, and getting people signed up. You know, with the Pfizer situation, you know, we had to pull back our initial plans because they had to cut back on their allotment, and that's fine.

But, you know, I think it's going better than most people would realize, or better than most people might think, just because these things do take a little bit of time, and these things do take a little bit of effort to sort of operationalize in a way that's efficient. And, also, if you wanna do in an orderly way, you've got to plan. You've got to know that you've got vaccine on board, you've got to know that you have your location set up.

You know, this rolled out so quickly. We didn't even know what the side effect profile was going to be—this anaphylaxis issue came up—and so, there's been a lot of sort of adjustment that's had to happen on the fly.

And it's understandable. This is going to take a week or two to get all of your gears working properly. I think you're going to see a remarkable increase in vaccine distribution over the next couple of weeks.

JOHNSON:
Well, you know, there are scattered reports of problems, such as vaccines being destroyed or given to donors instead of seniors, some people waiting all night to get in line for a shot outside a hospital.

There are so many more vaccine doses left to give over the next several months. How is it that we can avoid the situations going forward?

DOBBS:
It takes a while to get a well-oiled machine operational. And we're acting like this is a vaccine that we've had for a long time, like the flu shot—we know how you do it, we know the side effect profile, we know who to give it to. You know, it's really easy.

Within a week of us having a vaccine approved—we had the FDA EUA, right—and we had side effects stuff, we had to get people signed up. You know, for people with the flu vaccine, you know, you can get them set up, you know, a month in advance, but we still didn't even have our tiering—our 1A and 1B stuff—together.

So, it takes a little while to get it right, and it's better to get it right and to get it flowing quickly than to get it done quickly and chaotically.

JOHNSON:
There was this idea early on of administering this vaccine the same way we do others—the flu vaccine and others—through the local pharmacies, the hospitals, because they've got the refrigeration for the Pfizer formula, in particular, and so on.

Is the decentralized approach to distribution the right one so far, in your mind, as it relates to the COVID-19 vaccine?

DOBBS:
It's a mixture, and a lot of it has to do with the specifics of the vaccine.

If you think about the Pfizer vaccine, it comes—each bottle has five to six doses, and they come in lots of 975, and they have to be kept at -70°, -80° Celsius. So, if you send it to a small pharmacy—and first off, they can't digest it quickly and, if you don't have it planned perfectly, you going to waste doses out of each bottle—we're not going to get the bang for our buck.

There is nothing like some good planning, some good awareness, and some proper allocation. The Pfizer vaccine specifically is not going to be for every location. It needs to be sent places that can digest it properly.

And the Moderna vaccine still does have some limitations. You know, they come in about 100 doses. A lot of places, a lot of clinics, aren't going to give 100 doses, right? You know, if you go to your regular mom and pop, sort of private clinic, they're not going to be able to digest 100 doses in a day. And there's 11 doses in each vial—what if only three people show up that day? I mean, we're going to waste a lot of vaccine.

So, it's going to be sort of like a multi-level approach. There'll be places for having the distributive model, especially for places that can digest it quickly and have the plans in place. But also, there's going to be a place for these high-throughput drive-through sites, these points of dispensing where we can get it to folks. That's where we're going to see a lot of efficiency.

We've opened up our drive-through sites and they worked extremely well. Within two days, we gave 2200 doses of vaccine in this state. You know, if you think about our rollout, how that's been, I mean, we can ramp it up from there. I think you're going to see a lot of vaccine getting out.

You know, we're thinking about an efficiency point right now. But, at some point in the near future, we're really going to have to focus on equity—equity based on geography, based on can people even get out to a location—and that's going to be the other side of the coin, making sure we protect the people that needed to be protected.

JOHNSON:
Is the drive-through site, that idea, the best one you think that is on the table right now, or are there others that have promise?

DOBBS:
Well, to get a vaccine out quickly, there's nothing like a pod or a point of distribution. And that doesn't have to be a drive-through site.

That's what all of the hospitals have been doing with their employees. Where, basically, these things that we've worked with them for years to set up, we call these closed points of distribution where they can rapidly immunize people. If you think about a normal clinical encounter, there's a sign in, you have to sit in an office, and you can imagine how many people a doctor can put through an office in a day. That's a good way to do it.

Same thing with the pharmacy. How long does it take you to get your prescription filled when you stand there? You know, we can process through a drive-through site easily, you know, 40, 50 an hour when we have it up and running. It's hard to imagine getting 40 or 50 through a single, you know, pharmacy. You wouldn't want that many people inside.

So, it's going to be an all-of-the-above sort of choice. There are going to be situations, there are going to be people who are going to benefit, especially if we want to get it out to diverse areas because we've only got 18 drive-through locations operational now. We're going to expand that, keep in mind, but some people can't drive that far. So, it's going to take everybody.

JOHNSON:
What are some of the ideas you're kicking around there in Mississippi for getting into those neighborhoods where people don't have transportation, or maybe they're a little more hesitant to get involved because of history?

DOBBS:
Well, I'll tell you, one of our best allies in the state, when it comes to populations that maybe lack resources or disparity populations, are our community health centers, and we're working closely with those guys to make sure that they have access to vaccine for their staff and then for people over 75.

We did open it up—1B—for 75 and older just today, and we're starting to send vaccine out to clinics across the state that are volunteering to provide for that tier, but community health centers are really fantastic.

And then, you know, from there, we're also looking at pharmacies and everywhere. So, the more places you make it available, the more likely you'll get it to people who need it.

JOHNSON:
The community health centers, they have people working there with probably the most credibility among the audience they serve, don't they?

DOBBS:
Yes. Especially Mississippi, our disparity population is mostly going to be African-Americans. And within the African-American community, these community health centers have very good standing. We've spent a lot of time working with Black physician leaders, and yesterday we did a big press event with a local clinic, a well-respected physician leader. And some of her colleagues who have been practicing in the community have been here since, you know, basically segregation in Mississippi right?

So, they've seen the ugly side of Mississippi and they know how hard it can be. And when they get up and they say, "Hey, this is safe. This is going to help you and your family, and this is going to help us get pass this COVID pandemic," that message is unbelievably powerful.

JOHNSON:
Production issues have forced us to decide who gets the shot first, second, and third. How has that whole issue complicated matters for the states? Has it caused problems?

DOBBS:
It's been a little bit challenging. We've tried as much as we can to stay within the CDC framework of, you know, the 1As and 1Bs and CS and that sort of thing, but there's, understandably, a lot of desire. And, if you look at the mortality and the morbidity, to let the older folks and people with chronic medical conditions get it as early as possible. And that was a big debate in SCC and the Advisory Committee for Immunization Practices.

But, it's a balance, right? A lot of states have done their own sort of take on it. And so, we're trying to stay within the parameters, but within those different sort of shells, maybe pushing the vulnerable people to the top of those areas because that's where our mortality is.

If you look in Mississippi, of people who are 65 and older and diagnosed with COVID, 12% have died. Right, it's hard to ignore. And if you look at who's filling up the hospitals and who's suffering right now, it's people who are 65 and older.

So, we have sort of tweaked it a little bit and feel comfortable that getting older folks, you know, kind of before some of the factory workers and stuff— even though they are, certainly, absolutely essential—will pay big dividends as far as our mortality, but also the pressure on our healthcare system.

JOHNSON:
Is it just a matter, then, over communicating and having the right messengers?

DOBBS:
It is very difficult. And in this era of communication, sometimes it's hard to get the right message to the right people at the right time, as you can imagine. But yes, having the proper spokespeople makes a big difference.

But once we get into more and more of the essential workers, you know, there's been a lot of interest in having, you know, everybody kind of be at the front of line. Everybody can't be at the front of the line, right.

But the flip side of that is, without a doubt, we're going to have to live in a safe way for months to come. There's not going to be enough immunity in the population to cut down on transmission to speak of. What we can do right now, and it makes sense, is to go ahead and make sure our health system is protected as much as possible, which is absolutely overburdened.

In Mississippi, it is really bad. I know we've seen stuff out of California and we have some situations that are similar to that. Maybe not quite as extreme yet, but we're headed that way. So, we want to protect our health system and our vulnerable.

But once we get past that, it's going to be a little bit more tricky because we're going to open it up to larger and larger cohorts of individuals. And we've received a lot of concerned citizens who really want to go ahead and get immunized.

We do need a national conversation, national communication, and I think we would benefit from that. I know there is a national effort to have a communications campaign. But if we're not on the same page, and if everybody in the country is not hearing the same thing, there is going to be discord because people are able to find what they want to find to support their own personal narrative and, you know, obviously get them to where they would like to be.

But we are also super excited about the demand for the vaccine. I mean, it's kind of a two-edged sword, right? We are super excited about the vaccine, but it causes anxiety when people can't get it. So, we need to make sure we balance that interest without causing unnecessary anxiety within individuals.

JOHNSON:
And demand seems to be growing by the day. More and more people are getting off the bench and saying, "I'll take this."

DOBBS:
Absolutely. And I think now that people have seen other people get it—I got my second dose today, you know, trying to stand out and say, "Hey, look, I believe in this vaccine, I think is safe"—we are seeing more and more people step forward.

And, certainly, the people that are over 75 and the people that are over 65, we have seen a whole lot of interest. We get a lot of calls from people who were in that age group. So, we'll try to get it to them.

But within Mississippi, we have about 200,000 people who are over the age of 75. We've gotten one allocation of about 190,000 vaccine and about a little bit more than a third of that, about 40% with the long-term care. Right? So, that is kind of going. We don't have enough vaccine for everybody over 75.

So, that's the other thing is we do need to temper expectations, try to do the most we can with what we got. But understand that everybody's not going to be able to get it, even if they are within those high priority tiers.

JOHNSON:
How is your funding for this effort holding up? That's been a big debate here in Washington.

DOBBS:
It's been a little bit challenging. With a lot of things, you need a lot of runway to plan, right?

And I think—I kind of put us akin to the United States military going into World War II. We were unprepared, but why were we unprepared? It's because we diluted the military to a point where they didn't have mission readiness when Pearl Harbor happened, and they built up quickly, right?

Well, public health is the same thing. For decades, the public health system has been degraded to a point where it's basically minimally functional. We have elevated the value of clinical care, if you look at the amount of money we've invested in Medicare, private insurance, even Affordable Care Act.

You know, paradoxically, the Affordable Care Act was really tough on public health because there became this understanding that if people have insurance, public health is not necessary. And I think that we're starting to see you've got to have that critical public health infrastructure ready to react.

The other thing that we've seen in my career is we've seen this constant roller coaster of funding and then funding cuts. So, whenever there is a crisis, they say, "Okay, public health, build up real quick, respond!" And then we're pulling back.

Like with Ebola—you give us a bunch of money, almost more than we can spend in the timeframe allotted, but it can only be for Ebola—we can't build infrastructure that's going to be ready for the next thing—and then we pull it back. So, we never build a cohesive system.

And without a doubt, I promise you, if we look at it all the money that we've gotten for H1N1, for Zika, for Chikungunya, for Ebola, and now COVID—if we would cut that to about 80% or even less, and just gave it out over a steady period of time so that we could have an existing, strong public health infrastructure that's ready to react to any public health emergency, our country would be in so much better shape than it is right now.

JOHNSON:
Well, it's a new year. That means a new administration in the White House, a new Congress on Capitol Hill. What do you hope for out of Washington this year?

DOBBS:
What we desperately need is stability, constancy, and clear messaging.

You know, one of the challenges with this pandemic is we're trying to work with subsets of the population that are hearing a different set of guidelines and a different set of quote unquote "facts," right? We know how to do what we do here in Mississippi. You know, we are a system, a federal system such that states and public health are responsible for their own stuff.

But the stuff that the federal government can do is to be steady, is to be reliable, give us good information, give us good outreach, and have a steady message to all the population as much as possible. Everybody's not going to hear it, we get that, but there is nothing like consistency to lead to success.

JOHNSON:
And maybe think more strategically about the money?

DOBBS:
Yeah, absolutely. If we can think more strategically about the money—not only over the next six months, but over the next six to 10 years—how many trillions of dollars have we put into the COVID response now? Just a minimal fraction of that, if we had had the proper preparation going into it, would have saved countless thousands, maybe hundreds of thousands of labs.

When we looked at our models going into this pandemic, when we looked at the contagiousness and the mortality rate—which were about right even now, our early estimates were about spot on—we predicted 150,000 total deaths in the United States based on our pandemic influenza modeling. And it's a little bit different because you can get a flu vaccine out a little bit quicker.

But there are many things that we didn't account for in the model and a lot of it is the unsteadiness of the response and the inability of the public to follow or even have consistent guidelines that they are to follow.

JOHNSON:
You mentioned earlier there will come a time when we are trying to deliver these vaccines at enormous scale—millions and millions of doses going into the arms of people across the country, no matter where they live, no matter where they might be on the list.

What worries you about that process and what might or might not happen over the next four to six months?

DOBBS:
Well, I'm mostly worried about the anxiety people are going to have about not getting the vaccine. That's the next concern. And I know there's a perception that the vaccine hasn't gone out quickly enough.

But, you know, in the first two weeks we got about 62,000 doses, okay. That's a lot that we were able to distribute in Mississippi. So, the first week we got 12,000, the second week we got about 50,000, something like that. Well, they came in on the day before Christmas, basically, so that's a challenge. So, we were sitting on that.

So, there were a lot of functional things that kind of slowed us down. Most of the doses we've given health systems to distribute and they are really starting to crank it out.

But now, I think we're going to run out vaccine pretty soon, we're going to fill up. And there are going to be the people who say, "Hey, it's my turn now. Why can't I step up to the table?" Because there's just not going to be enough vaccine for everybody.

You know, we have, I think, maybe almost 400,000 people in Mississippi who are over 65. We haven't gotten near that much vaccine, and right now we're pulling down about 17,000 doses a month in Moderna, I think. So, obviously we're going to have demand outstrip.

After that phase though, after we sort of get over that hump of people who are super anxious to get it—which is great, people need to get it—it's going to be the vaccine hesitant folks. Unless we get people to buy in to the science and understand the importance of it, if 70% or 80% immunity is necessary for herd immunity, that's going to be a really tough hill to climb. Even in some healthcare communities, we've had trouble getting folks to take it.

So it's going to be—I think right now it's sort of like a vaccinating issue probably for the next couple of weeks to get caught up. After that, we're going to see demand exceed capacity. And then, after we get through that one, it's going to be vaccine hesitant folks who are going to perpetuate the vulnerability in our communities.

JOHNSON:
What kind of strategies have you thought about as it relates to being ready to deal with those different milestones that you've just outlined?

DOBBS:
Well, the distribution one, as far as getting vaccines in folks, I think we've got a pretty good plan and a system, and I think it's going to evolve really, really quickly. So, if you look at the CDC stuff, it looks like we're sitting on all this vaccine, you know, but that's just not really true. A lot of it is in transit, and a lot of it actually has been given and just hasn't been documented yet.

I'm really worried about the anxiety piece of people who want it who can't get it, because a lot of that is kind of out of our control. And so, I think a lot of it's going to be setting expectations and prioritizing. That's going to be very important.

But after that, the vaccine hesitancy piece, there's two big buckets of that. The one that's almost easier is the health disparity piece, because I think there are people who want, but don't trust. And if we can build that trust—and we're getting information based on community surveys and focus groups and that sort of thing, and working with leaders in the Hispanic community or the Black community in Mississippi—I think we can get over that gap pretty good.

It's the other sort of folks who might be a little bit more tough, the sort of "don't want, don't care" sort of group. We've perpetuated a horrible myth about coronavirus, that it's not deadly or even is not real. And then, we also have this nuttiness that everybody is going to get it anyway, so we've got to just go ahead and try to get it.

Our public health messaging from a global perspective has been so fragmented. I feel for the population. It's hard to pick the truth out from the noise, even when people who should know better don't mind getting out and yelling out nutty stuff from the rooftops, it puts us in a tough bind.

So, I think those are the things, but we are going to work aggressively on the health disparity issue. We've got to keep health disparity lens constantly activated. But other populations that are naturally resistant to government stuff, which is seen as government, that's going to be a really difficult thing to do.

JOHNSON:
Ultimately though, there is only one outcome, right? You have to get the job done.

DOBBS:
Yeah, we have to get the job done, and there's more than one objective and I think that's important to remember.

We do want herd immunity, that's great—that's tough, and it's not guaranteed. It is not guaranteed that we are going to get to herd immunity any time in the near future.

But the flip side of it is protecting the vulnerable, making sure people who are going to die or who would die don't die, people who were going to have severe illness don't get it. That's a little bit easier as your target.

And so, we've got to keep in mind our milestones. And so, obviously, we want to get to that first one first—it's a lot more achievable, but it also gets us on the road toward the herd immunity issue.

JOHNSON:
You can find links to the resources mentioned in this episode in the show notes.

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For Public Health Review, I'm Robert Johnson. Be well.