Tagged Vaccines

Journalists Weigh In on Biden’s HHS Pick

KHN senior correspondent Noam Levey discussed Xavier Becerra’s nomination to lead the U.S. Department of Health and Human Services with KQED’s “Forum” on Tuesday.

KHN senior correspondent JoNel Aleccia discussed the story of an organ transplant patient who died after receiving lungs infected with covid-19 on KFI’s “The Daily Dive” podcast on Wednesday.

California Healthline senior correspondent Anna Maria Barry-Jester discussed vaccine distribution in California with KALW’s “Your Call” on Thursday. She also was part of a panel discussion about inequities in the vaccine rollout with Venice Family Clinic’s “Health and Justice” series on Wednesday.

KHN “Navigating Aging” columnist Judith Graham discussed the need for vaccinating family caregivers against covid with Newsy on Thursday.

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Aging Public Health

Why AstraZeneca and J&J’s Vaccines, In Use the World Over, Are Still on Hold in America

The World Health Organization greenlighted emergency use of AstraZeneca and Oxford’s covid-19 vaccine this month, following in the steps of the United Kingdom, the European Union and others, who are already injecting it as quickly as possible into the masses.

But the United States is still waiting.

As covid deaths mount daily, critics say the Food and Drug Administration is moving too slowly. Meanwhile, the novel coronavirus is evolving, with new variants stalking populations the world over.

“We are truly in a race and this race is real — the more we get people vaccinated, the more it will tamp down the virus that is mutating,” said Dr. Monica Gandhi, an infectious diseases specialist and professor of medicine at the University of California-San Francisco.

The world has seven vaccines with completed clinical trials, yet the U.S. has approved only two, Gandhi and others lament.

AstraZeneca — after global trials that included some mistaken dosing — has not filed an application in the U.S., saying it first needs to finish its phase 3 U.S. trial. Simply put: AstraZeneca hasn’t applied for the U.S. job.

The company knows that the FDA doesn’t merely accept results from trials in other countries. And its confusing trial results pooled from differently designed clinical trials in Brazil and the U.K. raised questions about dosing as well as how well it works for people 65 and older. Germany and France have said not to administer the vaccine to older residents, while the World Health Organization said it was fine to do so.

The FDA — one of the oldest drug approval agencies on the globe — issued emergency use authorizations late last year for two vaccines manufactured by Moderna and Pfizer-BioNTech. It is reviewing an application from Johnson & Johnson, which filed Feb. 3, and the advisory panel is scheduled to discuss it at a Feb. 26 meeting.

“The FDA is not the villain here,” said Dr. Cody Meissner, a pediatric infectious diseases specialist at Tufts University who sits on the FDA’s vaccine advisory panel.

Drug approvals usually take months once an application is filed, but the FDA’s emergency authorizations for covid vaccines have been granted within weeks. FDA spokesperson Abigail Capobianco said its staff is working nights, weekends and holidays to prepare for the meeting — moving with a sense of urgency.

“FDA staff are mothers, fathers, grandparents, daughters, sons, sisters, brothers and more,” Capobianco said. “They and their families are also directly impacted by the work that they do.”

J&J’s vaccine, which received a billion dollars in development funds through Operation Warp Speed, uses an adenovirus — a vector that produces cold-like symptoms — to deliver a piece of genetic code that triggers an immune response in the body. It would be the first single-dose vaccine authorized in the U.S. — a possible game changer in getting more Americans vaccinated.

“People have been clamoring for it to be approved and everybody wants it to go faster,” said Dr. Amesh Adalja, a senior scholar at Johns Hopkins Center for Health Security who has called for more harmonization between approvals from the U.S., U.K. and European Medicines Agency.

“The question would be from a policy standpoint,” Adalja said. “Would the FDA be willing to say that what the EMA does is equivalent to them and they would have full confidence in the EMA decision?”

Despite the need for speed, the FDA said it will not cut corners. Before last fall, vaccines typically went through a full licensing process before being distributed to the public. The use of emergency authorization to give a vaccine to millions of otherwise healthy people has “never been done” before, said Norman Baylor, a former director of the FDA’s vaccine research and review office who now consults with pharmaceutical companies.

To prepare for J&J’s advisory committee, FDA staff members as well as the independent advisory panel will have analyzed thousands of data points to consider whether the benefit of a vaccine outweighs the risk of injecting it into millions of otherwise healthy people. The FDA is not required to follow the panel’s recommendation but usually does.

Meissner, who abstained in the vote for the Pfizer-BioNTech vaccine, said, “We want every vaccine to succeed.” Everyone on the planet needs immunization — billions of people.

“The more manufacturers that can provide vaccines, the better,” Meissner said. “I don’t think anyone would be against additional manufacturers.”

This moment — as Americans question why more tested vaccines like AstraZeneca and J&J’s vaccines aren’t approved — punctuates how the FDA’s drug approval process, honed over decades, is independent of other global agencies. Dr. Henry Miller, a senior fellow at the Pacific Research Institute who was the founding director of the FDA’s office of biotechnology, said it’s difficult to compare international vaccine development.

“It’s not like a footrace where everyone begins together,” he said. “From country to country, there are a lot of variables.”

Some are trivial, such as different application processes and whether the companies completed the forms properly. Others are more substantial — while many countries depend on academics on contract, the U.S. relies on full-time staffers who spend their careers focused on drug development, Miller said.

Dr. Peter Marks, director of the FDA’s Center for Biologics Evaluation and Research, said in a recent radio interview that the “FDA gets involved very early on in the process, that makes us unique among global agencies.”

FDA staff members have had discussions with some vaccine makers “about how they would do the work” even before the vaccines went to early clinical trials in humans. They are in contact through the various stages of manufacturing, Marks said.

Technically, AstraZeneca and the other vaccine makers have filed what are called “investigational new product” applications with the FDA. That means the companies early on submit the details of drug formulation, stability and laboratory work. They also provide results data at the end of each clinical trial phase.

AstraZeneca, which was awarded up to $1.2 billion through Operation Warp Speed to develop a vaccine, “remains in close, regular communication” with federal agencies, said AstraZeneca spokesperson Brendan McEvoy.

There are differences in what each country needs from the vaccines. The AstraZeneca vaccine will be “for a very different population than the Pfizer and Moderna vaccines,” former FDA staffer Miller said. The Pfizer and Moderna vaccines are more costly and demand cold-storage infrastructure that many developing countries can’t afford.

Plus, Miller said he believes the international agencies were eager to approve AstraZeneca. “Circumstances suggest they are willing to accept a somewhat lower standard — much like a drug intended to cure cancer makes you willing to accept greater side effects because the need is so great and the benefit is so great. It’s all risk, benefit and probability,” he said.

AstraZeneca’s acceptance abroad is enough for some people. “Why wait for another clinical trial to be completed?” asked Dr. Martin Makary, a professor of surgery and health policy at the Johns Hopkins University School of Medicine in Baltimore. “You have the real-world observation of the vaccine being given to millions of people.”

Gandhi, who has followed the clinical trials from across the globe, expressed more urgency. “The U.K. will get to herd immunity faster,” she said. “All of these wonderful things the FDA is doing that we are all so impressed by are taking too long.”

In October, the FDA released guidance for companies that seek approval in the U.S. It’s “pretty clear what designs were needed in the studies and what the FDA’s expectations were for the data,” said Dr. Jesse Goodman, former director of the FDA’s Center for Biologics Evaluation and Research, which regulates vaccines. He was also the FDA’s chief scientist from 2009 to 2014, leading its response to the 2009 H1N1 pandemic.

The agency asked for evidence that the vaccine’s benefits outweigh its risks based on data from at least one well-designed phase 3 clinical trial. To pass muster, it will need to prevent disease or decrease the severity of the disease in at least 50% of people vaccinated. Both Moderna and the Pfizer-BioNTech vaccines are well above that threshold, at 94.5% and 95% respectively.

Dr. Stanley Plotkin, a scientist and vaccine developer, said Pfizer and Moderna’s vaccines were greenlighted after large U.S. trials with “very clear results, high efficacy.” One challenge for AstraZeneca will be the variation in data — different trials with different dosages and population numbers. Clinical trials found the vaccine had an efficacy of 82.4% when two doses were given 12 weeks apart.

The FDA will dig into any incoming research numbers to determine how well each vaccine works with different doses and schedules. They will question whether they prevent serious or mild disease, while accounting for varying age groups of the trial populations, including subsets that may be more likely to get sick. Other aspects up for analysis will be the immunogenicity, or antibody response, and the safety data.

“Asking questions and asking for more data, that is exactly what they are supposed to do,” said Plotkin, now a professor emeritus at the University of Pennsylvania who consults for Moderna and others.

And, since multiple vaccine investigations are underway, FDA staff members will have reviewed the data from various applications — and may have questions that are not obvious to company researchers working on individual projects, said former vaccine regulator Goodman, who is now a Georgetown University professor.

FDA staffs work beyond the numbers as well and often do a “thorough investigation and validation of the plant” where vaccines will be produced, said Kevin Gilligan, a virologist and former unit chief at the federal government’s Biomedical Advanced Research and Development Authority. “You want to make sure there aren’t any remaining pathogens in there and all the equipment used is thoroughly clean and reevaluated,” Gilligan said.

Novavax, which received $1.6 billion through Operation Warp Speed in July, is developing a two-shot protein-based vaccine. After addressing FDA questions, Novavax ramped up full-scale manufacturing operations. Novavax spokesperson Silvia Taylor said the company has been in “ongoing contact” with the FDA and is “already beginning to submit” various parts of its application and data to agency officials. It expects initial results of its U.S. phase 3 trial before summer.

Taylor said Novavax has already “locked” its manufacturing process at scale and will be ready to distribute in the U.S. as soon as emergency use is approved.

KHN editor Arthur Allen contributed to this report.

As Covid Surged, Vaccines Came Too Late for at Least 400 Medical Workers

As health care workers in the U.S. began lining up for their first coronavirus vaccines on Dec. 14, Esmeralda Campos-Loredo was already fighting for oxygen.

The 49-year-old nursing assistant and mother of two started having breathing problems just days earlier. By the time the first of her co-workers were getting shots, she was shivering in a tent in the parking lot of a Los Angeles hospital because no medical beds were available. When she gasped for air, she had to wait all day for relief due to a critical shortage of oxygen tanks.

Campos-Laredo died of covid on Dec. 18, one of at least 400 health workers identified by The Guardian/KHN’s Lost on the Frontline investigation who have died since the vaccine became available in mid-December, narrowly missing the protection that might have saved their lives.

Esmeralda Campos-Loredo, a nursing assistant in Glendale, California, died of covid-19 on Dec. 18, 2020. (Joana Campos)

“I told her to hang in there, because they are releasing the vaccine,” said her daughter Joana Campos. “But it was just a little too late.”

In California, which became the epicenter of the national coronavirus surge following Thanksgiving, 40% of all health care worker deaths came after the vaccine was being distributed to medical staff members.

An analysis of The Guardian-KHN’s Lost on the Frontline database indicates that at least 1 in 8 health workers lost in the pandemic died after the vaccine became available. Unlike California, many states do not require a thorough reporting of the deaths of nurses, doctors, first responders and other medical staff members. The analysis did not include federally reported deaths in which the name was not released and may be missing numerous recent deaths that have not yet been detected by The Guardian and KHN.

The vaccine is now widely available to health care workers around the country and since mid-January, and covid-19 cases have been trending downward in the United States.

Sasha Cuttler, a nurse in San Francisco, has been gathering health care data for one of California’s nursing unions. Cuttler was alarmed and disheartened to see the number of deaths still surging weeks after the vaccination became widely available. “We can prevent this. We just need the means to do it,” said Cuttler, who noted that, nearly a year into the pandemic, some hospitals still lack adequate protective gear and proper staffing. “We don’t want to be health care heroes and martyrs. We want a safe workplace.”

Stockton nurse Barbara Clayborne became sick the same week her colleagues started receiving their first doses of the vaccine.

The 22-year staff member and union activist at St. Joseph’s Medical Center had picketed last summer to demand more help for the beleaguered nurses treating covid patients.

Though she worked on what was considered a relatively low-risk postpartum care unit, she was advocating for her colleagues in the intensive care unit, many of whom were overwhelmed by the number of patients they were responsible for.

Barbara Clayborne, a registered nurse in Stockton, California, died of covid-19 on Jan. 8, 2021.(Ariel Bryant)

“We know what it’s like to work a full 12-hour shift and not be able to drink water or sit down or go to the bathroom,” Clayborne told the Stockton Record in August. “It’s been chaos.”

In mid-December, Clayborne, who had asthma, became ill in mid-December. She had been exposed to a patient who hadn’t yet been diagnosed with covid, said her daughter Ariel Bryant. Clayborne died on Jan. 8.

“She was the best mom and grandmother — and she was a great role model for me,” said Bryant, who herself became a nurse. Bryant works in an intensive care unit in Southern California — as the same type of nurse her mother fought so hard to protect.

If the vaccine had come just a few days earlier, it might have saved Tennessee fire chief Ronald “Ronnie” Spitzer and his department’s dispatcher, Timothy Phillips.

Spitzer and his crew from the Rocky Top Fire Department were called to a medical emergency on Dec. 11 but weren’t told until later that the patient had tested positive for covid. Both Spitzer, 65, and the firefighter who accompanied him came down with the virus. A few days later, Phillips became ill as well.

Spitzer, a 47-year firefighting veteran, was already hospitalized when his co-workers got their first doses of the vaccine in January, according to Police Chief Jim Shetterly. He died on Jan. 13, and Phillips, 54, died a few days later.

The state of Tennessee does not publish statistics on health care worker deaths, but 10 of the 22 Tennessee health care worker deaths identified by the Guardian/KHN occurred since the vaccine rollout in December.

Shetterly said his town of 1,800 has been shattered by the losses. “Everyone knows everyone here. It’s tragic when it hits the nation. But, when it’s in your town, it really hits home,” he said.

Gerald Brogan, director of nursing practice for National Nurses United, said many hospitals hadn’t done adequate planning to be ready for the recent surges, which put exhausted health care workers at extra risk.

“When there are more patients in, there’s more chaos in the hospitals and it’s harder for workers to be safe,” he said. During the recent surge, “we had nurses breaking down because of the influx of patients and the emotional and physical toll that took on workers.”

Even once all health care workers are vaccinated, he said, health care administrators would need to remain vigilant on worker safety.

He said that surge preparations, extra safety equipment, contingency staffing plans and facilities like negative-pressure rooms to stop disease from spreading around hospitals should be a regular part of preparing for potential future pandemics.

KHN reporters Shoshana Dubnow and Christina Jewett contributed to this report.

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Calling All Vaccinators: Closing the Next Gap in Covid Supply and Demand

Beating back covid right now comes down to balancing supply and demand.

With hopes pinned to vaccines, demand has far outstripped the supply of doses.

But, as an increasing number of vaccine vials are shipped in coming weeks, the concern about shortages may well shift to human capital: the vaccinators themselves.

“We need to mobilize more medical units to get more shots in people’s arms,” Jeff Zients, coordinator of President Joe Biden’s covid-19 task force, said at a briefing earlier this month.

Already, there have been scattered reports that vaccinators are in short supply in some areas.

“Absolutely, we do need more,” said Tom Kraus, vice president of government relations for the American Society of Health-System Pharmacists, whose members work in hospitals, clinics and large physician practices.

After all, vaccinating America is a huge undertaking.

“We are planning to vaccinate a lot more people over a shorter period of time than we’ve ever done before,” said L.J Tan, chief strategy officer of the Immunization Action Coalition, which distributes educational materials for health care professionals and the public across a range of vaccination topics.

Each year the U.S. vaccinates 140 million to 150 million residents against influenza, “but what we’re talking about now is much more intensive,” he said. For covid, the goal is to get vaccines out quickly to all those eligible in a country of 330 million people.

A state-by-state survey would be required to estimate how many total vaccinators are needed nationally, Tan said.

Still, experts are cautiously optimistic that this won’t be a hard problem to fix, pointing to efforts underway to recruit current and retired medical professionals, as well as medical students and nurses in training.

“As long as we continue to see this interest in volunteering, we should have a sufficient workforce to do it,” said Deb Trautman, president and CEO of the American Association of Colleges of Nursing.

Not just anyone can be a vaccinator. One can’t merely walk into a center and offer to help give shots. The training requirements vary by state.

To boost the effort, both the Trump and Biden administrations, using an emergency preparedness law first adopted in 2005, expanded liability protections.

With the recent expansions, those qualifying include pharmacy interns and recently retired doctors and nurses, as well as physicians, nurses and pharmacists. The government estimates there are about half a million inactive physicians and 350,000 inactive registered nurses and practical nurses in the United States.

States are also greenlighting dentists, paramedics and other first responders, said Kim Martin, director of immunization policy at the Association of State and Territorial Health Officials.

Some are also turning to nursing and medical schools, where faculty and students are often eager to participate. More than 300 schools nationally have signed a pledge offering to help administer the vaccine, according to the American Association of Colleges of Nursing.

The University of Houston College of Nursing, for example, altered its curriculum specifically to prepare students for administering covid vaccines — and teams of students and faculty have helped at community vaccination sites.

Others are joining the effort.

The Medical Reserve Corps, a national network of volunteer groups, has more than 200 units in about 40 states, Puerto Rico, American Samoa and the Northern Mariana Islands assisting with various vaccination efforts, including administering the shots, according to a Health and Human Services spokesperson.

And the military is pitching in, too, with the Pentagon approving the use of more than 1,000 active-duty service members to help the Federal Emergency Management Agency with mass vaccinations sites, the first one set for California.

Although some of these groups give ballpark figures of volunteers, it’s hard to tally just how many have stepped forward in recent months to help vaccinate.

Becoming a Vaccinator

“It should not be left to just anyone that is willing, as there are clinical skills and preparedness that is required,” said Katie Boston-Leary, director of nursing programs at the American Nurses Association.

Even those skilled in giving shots may need a training booster in the war against covid.

When she volunteered, Boston-Leary said, she was required to complete four to six hours of online training across a wide range of topics, from the optimal way to administer intramuscular injections, to specific information about the two vaccines now on the market.

“Even a nurse like me has to go through that training,” said Boston-Leary.

To aid states in setting up training, the Centers for Disease Control and Prevention offered recommendations that all health care staff members receive training in covid vaccination “even if they are already administering routinely recommended vaccines.”

The CDC has different training modules, based on experience level. For instance, there’s a module for those who have given vaccinations in the previous year, but a different one for those who haven’t done so for more than a year. The time required to complete programs varies — people with the most recent experience require less total training time.

Tan said training laypeople with no medical background to give vaccines “is not the way to go.”

Instead, such volunteers can be used to help with logistics, such as directing people to the right areas, managing traffic, moving supplies around and similar duties.

Training programs exist even for people who aren’t vaccinators but assist with storing, handling or transporting the vaccines. That’s important because the two vaccines currently in use — one from Pfizer-BioNTech and one from Moderna — have different storage requirements.

They are shipped in multidose vials, which is not unusual for vaccines. The vaccinators themselves often draw up the syringes out of the vials, said Tan.

To avoid slowdowns as patients move through the lines, some vaccination centers have other trained staffers pre-fill individual syringes. Anyone doing this task should be “someone trained in administering vaccines as well,” said Tan.

At the clinic where Katie Croft-Walsh, 65, volunteered recently in San Antonio, her only job was to administer the vaccine. Other volunteers took care of registering patients, pre-filling the individual syringes and other logistical efforts.

She decided to volunteer after hearing that help was needed. The move came with a bonus: She would get the vaccine herself at the end of her first day participating, something she already qualified for based on her age but had been unable to secure.

A practicing lawyer, Croft-Walsh previously worked as a registered nurse and kept her license current by taking required courses each year since leaving her hospital job in 1998.

Training occurred on her first day at the mass vaccination site and covered details about each type of vaccine, along with the types of syringes available, the right place to inject the dose and other information. Her group, which she said included nurses, dentists, pharmacists and upper-level nursing students, were trained and overseen by health department physicians.

The patients were all thrilled to get a dose.

“Everyone was very kind and nice,” even if they had to wait a bit in line, she said.

She liked the experience so much that she has volunteered at more clinics — and plans to start volunteering with fire departments as they begin community clinics in her city.

“It made me remember why I went into nursing in the first place,” said Croft-Walsh.

Remember, No Squeezing!

To ensure safety, training is important, Martin of the state health officers group said. It’s not that hard to give an intramuscular injection, but you need to place it in the right spot. For adults, that area is in the deltoid muscle, “not too far up the shoulder, not too far down,” she said, both to avoid injury and to make sure the vaccine goes into the muscle.

Training videos show vaccinators how to find the ideal location, first locating the bony point in the shoulder, then measuring two or three finger widths down and placing the needle in the middle of the arm.

Administering an intramuscular vaccine too high on the shoulder can cause a rare and painful injury. Such injuries were more common years ago when influenza vaccines were first rolling out, said Tan of the immunization coalition. Training on proper technique helped reduce cases since then, he said, and is also part of current efforts to train vaccinators.

It’s also important not to pinch patients’ arms when administering the vaccine, said Tan, responding to a question about a hashtag making the rounds on Twitter called #DoNotSqueezeMyArm.

For intramuscular injections to be most effective, the needle needs to penetrate the muscle, not fat.

“When you squeeze the arm, it pushes up the fat layers,” said Tan.

Those getting the vaccines, he said, can play a role, too.

“I encourage patients to ask questions,” said Tan. “If they’re concerned their arm is being squeezed, speak up. Not in a hostile manner, but say something like, ‘Hey, I read this thing about not squeezing arms. Can you explain why you’re squeezing mine?’”

After Billions of Dollars and Dozens of Wartime Declarations, Why Are Vaccines Still in Short Supply?

The U.S. government has invested billions of dollars in manufacturing, used a wartime act dozens of times to boost supplies and yet there’s still not enough covid vaccine on the way to meet demand — or even the government’s own goals for national immunization.

President Joe Biden, in remarks at the National Institutes of Health this month, said the nation is “now on track to have enough supply for 300 million Americans by the end of July.” But at the current rate of production, Pfizer and Moderna will miss their targets of providing at least 100 million doses each by the end of March, let alone 200 million more doses each has promised by July.

Moderna would need to more than double its vaccine production rate from January — when it made roughly 19 million doses — to meet its contractual obligations. Pfizer supplied 40 million vaccine doses by Feb. 17. It has roughly six weeks left to deliver the first 120 million doses it has promised.

Biden and officials from the two companies say they are rapidly expanding production capacity. But critics are lining up. They want to know whether the government did enough, fast enough, to guarantee that companies would meet the urgent challenges of the pandemic. As for the manufacturers bolstered by extraordinary sums of taxpayer money, why did they not share technology and know-how sooner, or move more quickly into strategic production partnerships?

Experts say it’s complicated, noting that the output of raw materials and assembly lines can’t be ratcheted up 10,000-fold at the push of a button — and that the effort thus far has been close to miraculous. They cite bottlenecks in at least three areas: the production of specialty lipids, fatty materials that are a primary component of the Moderna and Pfizer-BioNTech vaccines; the hundreds of millions of glass vials that hold the vaccine; and the sterile automated assembly lines where vaccine moves from bulk containers into vials before shipment.

U.S. officials have run headlong into the limits of the Defense Production Act, a Korean War-era law that allows the federal government to ramp up supplies of critical materials in times of national emergency. The vaccine manufacturing process relies on a complex supply chain, from sourcing raw materials and equipment to designing chemical processes, building production lines and hiring and training workers.

Also, experts note, no one knew which vaccines would prove effective.

“A year ago there was no commercial market for mRNA product. There was scientific research and pharma making small-volume clinical lots. Now we need billions of doses, in the space of a year. That’s overloading the supply infrastructure,” said Kevin Gilligan, a senior consultant with Biologics Consulting and a former official with the Biomedical Advanced Research and Development Authority, or BARDA, a federal agency created in 2006 to deal with pandemics and bioterrorism.

As of December, the Trump administration through its Operation Warp Speed initiative had obligated nearly $14 billion for vaccine development and manufacturing, including investments to expand U.S. capacity, according to a Government Accountability Office report in January. The administration invoked the Defense Production Act on at least 23 vaccine-related contracts, in part to prioritize the government’s contracts over others, according to a KHN review of the federal contracts database, contracts obtained by the nonprofit group Knowledge Ecology International, GAO and government news releases.

They include the December contract that the Department of Health and Human Services signed with Pfizer for another 100 million doses, on top of the initial 100 million it committed to last summer. That contract, worth $1.95 billion, included DPA provisions to give the company priority access to raw materials and spare parts for factories, according to a former administration official.

The DPA has also been used in vaccine contracts with Moderna, Johnson & Johnson and other drug companies for hundreds of millions of doses. On top of that, the law has been invoked for at least 10 contracts with companies making needles or syringes. It’s been used to require glass makers Corning and SiO2 Materials Science to prioritize vial production for vaccine production, and in contracts for aspects of manufacturing with companies like Emergent BioSolutions, Fujifilm Diosynth Biotechnologies and Grand River Aseptic Manufacturing.

Operation Warp Speed awarded Emergent BioSolutions $648 million last year to boost the manufacturing capacity it needed to enter agreements with Johnson & Johnson and AstraZeneca — worth at least $615 million and $261 million, respectively — to help make their vaccines. Grand River Aseptic Manufacturing won a $160 million award from BARDA and has contracted with Johnson & Johnson to fill vials and finish packaging of its single-shot covid vaccine, which is expected to get emergency authorization from the Food and Drug Administration as soon as this month but will only have a few million doses available initially.

The Biden administration has expanded its use of the wartime act to prioritize equipment like filling pumps and filtration systems for Pfizer. “We told you that when we heard of a bottleneck on needed equipment, supplies or technology related to vaccine supply, that we would step in and help,” Tim Manning, the White House official leading the administration’s covid supply efforts, said during a February press briefing.

Yet it can do only so much, according to medical supply chain experts. Prashant Yadav, a senior fellow at the Center for Global Development at Harvard University, said it could take months for the impact of that DPA action to be felt because of the time it takes to procure equipment and get it installed, with each step tightly regulated.

The U.S. is unlikely to get a meaningful bump in capacity “unless we think about co-production deals,” in which a drug company agrees to manufacture a competitor’s vaccine, said Tinglong Dai, an associate professor at Johns Hopkins University’s Carey Business School.

So far, such arrangements have proliferated in Europe — which has less capacity to produce drugs than the United States does. Deals with other major vaccine manufacturers have been less common on the U.S. side of the pond.

“Though we have not partnered with, say, another large pharma for production, we have built strategic partnerships with a number of organizations that have been instrumental to our scaling up and meeting supply and commercialization plans,” Moderna spokesperson Ray Jordan said in an email.

Moderna this month said that its manufacturing process would scale up rapidly in the coming weeks, that it would provide the U.S. between 30 million and 35 million doses in February and March and between 40 million and 50 million doses monthly from April to July. The company declined to elaborate on what made the boost possible.

Vaccine manufacturers long ago should have been sharing technology and expertise to boost production in the U.S. and Europe, and especially in developing countries, said James Love, director of Knowledge Ecology International, a nonprofit focused on patent rights.

“We’ve wasted about a year by not doing some of the obvious things,” he said. “The rhetoric is that it’s an emergency. But on the scale-up of manufacturing, you just don’t see it.”

It’s not that simple, others say. “There wasn’t any excess capacity available in the United States a year ago. Zero,” Paul Mango, a former HHS official heavily involved in Operation Warp Speed, said regarding vaccines. “It’s getting the equipment. It’s quality control. It’s getting the employees. People make it sound like this is easy. You can’t just push 400 workers and say, go at it.”

Each Pfizer-BioNTech or Moderna shot contains billions of lipid nanoparticles, each particle containing four lipids and a strand of the nucleic acid RNA, the five pieces assembled in a way that allows the RNA to enter our cells and create a particle that stimulates the immune system to defend against the covid virus.

The lipids, which are made only in a handful of factories, have been a major supply problem. “No one has ever thought of a scenario where we would use lipid nanoparticle formulation for [billions of] doses,” Yadav said. “We have not invented a process for doing lipid nanoparticles at scale.”

Two of the lipids in the vaccine, cholesterol and DSCP, have long been used in industry to shape and buffer chemical formulations. A third lipid prevents the particles from clumping together. A fourth enables the lipid shell of the vaccine to fuse with human cells and, once inside the cell, to crack open so the RNA can move to a structure called a ribosome and make proteins that stimulate immunity.

All of these raw materials are produced under regulated conditions — in Massachusetts, Missouri, Colorado and Alabama by companies under license with Moderna, Pfizer or Acuitas Therapeutics, which was co-founded by Pieter Cullis, a University of British Columbia professor who is considered the grandfather of lipid nanoparticle technology.

Before the pandemic, these companies produced meager amounts for use in small clinical trials, laboratory experiments or in one licensed drug, patisiran, which is used to treat a rare genetic disease in about a thousand people worldwide. Now they are producing thousands of kilograms of the stuff, said Stefan Randl, a vice president at Evonik, a lipid maker. Evonik recently announced it would scale up production at two German sites, possibly in the second half of the year, to be used in the Pfizer-BioNTech vaccine. The company last year bought a U.S. lipid manufacturer in Alabama.

“All of a sudden the quantities had to be ramped up a thousand-fold or more,” Randl said. “This is the biggest bottleneck.”

Several elements of the vaccine, including lipids and enzymes used in making the mRNA, until recently were produced using animal products such as sheep’s wool, said Andrew Geall, chief scientific officer at Precision NanoSystems, which designs equipment for mixing the mRNA and lipids. Animal products could cause contamination or disease, even in minute quantities, so manufacturers now use synthetic chemicals.

Luckily, the cosmetic industry — a major user of some of the same lipids used in the vaccines — has been switching from animal products in recent decades, noted Julia Born, an Evonik spokesperson.

Still, only a limited number of companies globally have expertise and facilities to make the lipids, said Thomas Madden, CEO and a co-founder of Acuitas, and they’ve all struggled to move from quantities produced in a laboratory to industrial-scale production. For instance, he said, hazardous solvents and chemicals used in laboratory procedures need to be avoided in industrial processes, where they could give rise to workplace safety issues.

“This is a hugely complex supply chain,” Madden said. “Once you address a bottleneck at one point, you identify the next bottleneck in the process. It’s a bit of a game of whack-a-mole.”

Although it’s not particularly difficult to make the lipids used in vaccines, it takes time to get FDA authorization of a facility that can make them in high quantities, said Cullis, the UBC professor. It would take two to three years to start such a factory from scratch, so instead, Moderna and Pfizer-BioNTech have been hooking up with existing manufacturers and getting them to convert to lipid production, he said.

Another bottleneck is “fill/finish” — getting the finished vaccine into vials or syringes so the shots can be shipped to customers. Vaccine filling lines require extremely high levels of efficiency and sterility, and few companies in the world have this capacity, said Mike Watson, former president of Valera, a Moderna subsidiary. Moderna has hired Catalent, a contract manufacturer that recently experienced delays that slowed the release of some doses, to fill and finish U.S. doses at its facility in Bloomington, Indiana. At least two other companies will do the same for Moderna’s vaccine supply abroad.

In January, the French multinational Sanofi — whose own covid vaccine has been delayed by poor performance in producing immunity — agreed to offer its fill/finish line in Germany for the Pfizer-BioNTech vaccine. That line isn’t expected to be running until July.

In the U.S., the number of vaccine doses shipped to states has ticked up in recent weeks, partly because Pfizer said its five-dose vials actually provide six shots. Moderna is seeking FDA permission to add up to five doses to its 10-dose vials.

Pfizer has said it is manufacturing raw materials in St. Louis, the active ingredients for the vaccine in Andover, Massachusetts, and filling vials in Kalamazoo, Michigan.

CEO Albert Bourla, with Biden at his side in Kalamazoo on Friday, said the company added lipid production capabilities at plants in Michigan and Connecticut, as well as fill/finish lines in Kansas. He said it has significantly cut the average time it takes to make doses — from 110 days to 60 days.

“Today, during this meeting, the president challenged us to identify additional ways in which his administration could help us potentially accelerate even further the delivery of the full 300 million doses earlier than July,” Bourla said. “The challenge is accepted, and we will try to do our best.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Countless Homebound Patients Still Wait for Covid Vaccine Despite Seniors’ Priority

Opening another front in the nation’s response to the pandemic, medical centers and other health organizations have begun sending doctors and nurses to apartment buildings and private homes to vaccinate homebound seniors.

Boston Medical Center, which runs the oldest in-home medical service in the country, started doing this Feb. 1. Wake Forest Baptist Health, a North Carolina health system, followed a week later.

In Miami Beach, Florida, fire department paramedics are delivering vaccines to frail seniors in their own homes. In East St. Louis, Missouri, a visiting nurse service is offering at-home vaccines to low-income, sick older adults who receive food from Meals on Wheels.

In central and northern Pennsylvania, Geisinger Health, a large health system, has identified 500 older homebound adults and is bringing vaccines to them. Nationally, the Department of Veterans Affairs has provided more than 11,000 vaccines to veterans who receive primary medical care at home.

These efforts and others like them recognize a compelling need: Between 2 million and 4.4 million older adults are homebound. Most are in their 80s and have multiple medical conditions, such as heart failure, cancer, and chronic lung disease, and many are cognitively impaired. They cannot leave their homes or can do so only with considerable difficulty.

By virtue of their age and medical status, these seniors are at extremely high risk of becoming seriously ill and dying if they get covid-19. Yet, unlike similarly frail nursing home patients, they haven’t been recognized as a priority group for vaccines, and the Centers for Disease Control and Prevention only recently offered guidance on serving them.

“This is a hidden group that’s going to be overlooked if we don’t step up efforts to reach them,” said Dr. Steven Landers, president and CEO of Visiting Nurse Association Health Group, which provides home health and hospice care to over 10,000 people in New Jersey, northeastern Ohio and southeastern Florida. His organization plans to launch a pilot home vaccination program for frail patients this week.

Jane Gerechoff, 91, of Ocean Township, New Jersey, is waiting for the group to vaccinate her. She had a stroke more than a year ago and has difficulty breathing because of a serious lung disease. “I can’t walk; I’m in a wheelchair. There’s no way in the world I could get the vaccine if they didn’t come out to me,” she said in a phone interview.

Although Gerechoff doesn’t go out, she lives with an adult son who interacts with people outside the house and she receives help from physical and occupational therapists at home. Any one of them could bring in the virus.

Reaching homebound seniors presents many challenges. At the top of the list: Home care agencies and hospice organizations don’t have access to covid vaccines either for their staff or patients.

“There is no distribution of vaccines to our members, and there has been no planning surrounding meeting the needs of the people we serve,” said William Dombi, president of the National Association for Home Care & Hospice.

Organizations that administer vaccines also complain they’re not being paid enough by Medicare to cover their costs — primarily staff time and effort. (The shots are free because the federal government is paying for them.) Making a vaccine house call requires about an hour on average, including travel, time interacting with patients and post-vaccination monitoring of people for potential side effects, according to program leaders.

Medicare reimbursement for the first shot is $16.94; for a second shot, it’s $28.39, according to Shawna Ramey, a consultant who presented the data at a recent American Academy of Home Care Medicine webinar. “The actual cost of these visits is closer to $150 or $160,” Dombi said.

Then, there are issues with cold storage and transportation for the Pfizer-BioNTech and Moderna vaccines. Both vaccines are fragile after being thawed and need to be handled carefully, according to the new CDC guidance on vaccinating homebound adults.. Once vaccine vials are opened, shots need to be delivered within six hours, according to instructions from Pfizer and Moderna.

Those requirements have proved too burdensome for Prospero Health, which serves 9,000 seriously ill patients in their homes in 20 states, including nearly 2,000 homebound patients. Fewer than 10% have been vaccinated, said Dr. Dave Moen, Prospero’s medical group president.

Things will become easier if vaccines from Johnson & Johnson and AstraZeneca receive approval, as expected, he suggested. Both of those vaccine candidates are more stable than the Pfizer and Moderna vaccines and would be easier to administer in the home, Moen said.

Palmer Kloster, 84, of Bradley, Illinois, receives care from Prospero under a contract with his Medicare Advantage insurer, UnitedHealthcare. He’s a largely immobile polio survivor who has undergone open-heart surgery and receives care from paid helpers for four hours a day.

“I really need someone to come here and give me a shot,” he told me in a phone conversation. “I don’t want that disease [covid-19]. At my age, it would be very detrimental.”

In Boston, Mary Gareffa, 84, is grateful that a physician she knows and trusts, Dr. Won Lee, came to her house in early February to vaccinate her. “I haven’t been out of the house in about eight years, except by ambulance,” said Gareffa, who has stomach cancer, weighs 73 pounds and broke her hip this summer after a bad fall.

It’s essential to reach out to patients like Gareffa, said Lee, a geriatrician who works with the Boston Medical Center’s home-based program. “It’s worth providing quality of life and reducing suffering, and covid-19 causes nothing but suffering,” she said. The Boston program has vaccinated 84 people as of Feb. 12.

The vaccines come from the medical center’s supply. Before going out, staff members call patients and address any concerns they might have about getting the shots. Most are African American and many families want to know whether the vaccine will make their frail parents or grandparents sick. “They need to hear that it’s safe to get a shot from someone who knows their medical issues,” Lee said.

Wake Forest’s house call program is sending out a doctor, nurse or physician assistant paired with a pharmacy resident to deliver vaccines. About 200 people are served through the program, most of them in their late 70s or early 80s with five or more medical conditions, said Dr. Mia Yang, the program’s director.

Wake Forest’s goal is to provide vaccine house calls to up to 40 patients a week and include family caregivers if there’s adequate supply, Yang said.

Robert Pursel, 69, who has severe osteoporosis and fluid retention in his feet and legs, and his wife Gail, 72, who has serious back problems, both received Pfizer vaccines in late January from Geisinger at their home in Millville, Pennsylvania. At first, Robert said he was skeptical, but now he’s glad he said yes. If a Geisinger nurse hadn’t come to them, he wouldn’t have been able to get out on his own.

Because of his swelling, “I can’t get my shoes on,” Robert said, and “I’d have to walk barefoot through the snow and ice out there.”

The Do’s and Don’ts on Social Media for Vaccine Haves and Have-Nots

Posting about their day is a regular practice for Generations Y and Z, especially when they have something novel or exclusive to share. So, in the thick of a global pandemic, and with the shaky rollout of covid vaccines making them somewhat of a holy grail, it’s no surprise selfies featuring the coveted shot are infecting social media timelines.

It might engender envy, even outrage, especially if the person posting seems to have cut the line. But what if the intention was to encourage others to also get the shot? Does that make it OK?

Since the pandemic began, people around the world are increasingly living out significant portions of their lives online. But with 72% of the American public using some type of social media, according to the Pew Research Center, who sets the rules for proper social media etiquette?

“This is a totally new type of world to have a pandemic in,” said Catherine Newman, the etiquette columnist at Real Simple and author of the book “How to Be a Person.” One advantage of using social media, she said, is that people can create waves of public opinion from which everyone can benefit. Newman, who also volunteers at a hospice, was vaccinated and posted a selfie. She said the selfies can help address some of the public health mistrust issues that have contributed to vaccine hesitancy.

“I don’t want to see a picture of your yacht on social media,” she said. She’d rather see covid vaccine selfies but cautions users to be mindful of the caption they choose.

After all, nearly 500,000 American lives have been lost in the pandemic and stark disparities have emerged in vaccination rates — especially among communities of color and older adults who are in the highest risk categories.

It raises the question: Is posting a vaccine selfie on your social media account a faux pas or still par for the course?

Elaine Swann, a lifestyle and etiquette expert, a certified mediator in the state of California and the founder of the Swann School of Protocol in Carlsbad, California, echoed those precautions. “RNs and front-line workers have a very different story to tell than a 20-something-year-old who got vaccinated for some obscure reason,” she said.

At the same time, she said, it’s not necessarily clear how someone came to be eligible for the vaccine. A person could present young and healthy at first glance but could have a health condition or other qualifying criteria. “We don’t know,” she said. She advises that posters follow what she calls the three core values of manners: respect, honesty and consideration.

And the same goes for people reacting to the posts.

George Francois, 35, a center director at Children’s National Hospital in Washington, D.C., chronicled his covid vaccination on Facebook. Looking at the overall death and infection rates in the African American community, he considered his post a public service. “I could inspire others to get it without having to talk to them directly,” he said.

George Francois receives his first covid-19 vaccine dose at Children’s National Hospital in Washington, D.C. Given the overall death and infection rates in the African American community, he considered his social media post a public service. (George Francois)

It’s a sentiment shared by J. Shawn Durham, 44, an actor in Washington, D.C., and an unintentional “vaccine vulture.” He got a call from a friend of a friend to get vaccinated after a scheduled patient missed their appointment — leaving a critical dose that otherwise might have gone to waste. “I am healthy. I am Black. I am scholastic, so I know about our history and the Tuskegee experiments,” he said. And, given that history, Durham posted his selfies to “lead by example,” he added. “The white and the wealthy are getting vaccinated. I want Black people to want to get vaccinated too.”

Francois didn’t receive any backlash from his post and didn’t think it was a big deal. “A lot of people post their HIV and covid test results,” he said.

Bottom line: It’s common among younger adults to publicly share things some older adults may consider to be far too personal.

“It’s kind of tacky sometimes, I think, but there’s a lot of misinformation out there,” said Emilio Delgado, 31, who was born in Puerto Rico and now lives in D.C. He posted in part to foster confidence in the vaccine — to let his connections “see that someone they knew has taken it and didn’t grow a third eyeball,” he said of his hesitant followers. For that reason, he added, it was worth it.

Delgado, a local actor and patient instructor at the George Washington University School of Medicine and Health Sciences, had access to the vaccine because in this role of “standardized patient” he is often called in to role-play ultrasounds with fourth-year medical students. He makes the bulk of his income through such patient instruction and is frequently at the hospital — a place generally considered high-risk — so he’d rather be vaccinated.

For Signe Hawley, 34, a researcher and volunteer firefighter in the foothills of northwestern Boulder, Colorado, getting the vaccine — and posting about it — was an emotional experience.

Signe Hawley receives her first covid-19 vaccination shot in Boulder County, Colorado. She shared the image on Facebook in honor of her father, Joe Hawley Sr., 67, who died from complications of covid in Connecticut in April. (Signe Hawley)

Earlier in the pandemic, she made the difficult decision to pull back from her volunteer duties to protect her wife and 2-year-old daughter. But because she had been a first responder in her community, she became eligible for the vaccine sooner than expected. “I wouldn’t cut the line,” said Hawley. “But when given the opportunity, I wouldn’t pass it up either.”

For Hawley, the hardest side effect she faced after getting the vaccine was the depth of grief and sadness that surfaced surrounding the loss of her father, along with thoughts of all of the other lives lost “in the mismanagement of this,” she said.

Her father, Joe Hawley Sr., 67, died in early April from complications of covid-19 at Norwalk Hospital in southwestern Connecticut. His family was not allowed into the intensive care unit at any time during his bout with covid. And her interest in volunteerism and service is something she inherited from her father, a “humanitarian at heart,” who was involved and committed to the New England community where he lived.

“To be vaccinated for something that my father died from is so surreal,” she said, her voice breaking. Sharing her story and the vaccine photo was a way to honor her father. “This is one step to lessening the impact of death and severe health complications with covid, but it’s not the end of it,” she said.

Ultimately, she said, the more people vaccinated the better off we all are.

“We’re all posting this hoping to get buy-in,” said national etiquette expert Diane Gottsman, an author and founder of the Protocol School of Texas, a company specializing in corporate etiquette training based in San Antonio. Know your audience, she advised. And another important reminder: Follow Federal Trade Commission guidelines, which advise against posting vaccination cards containing identifying information that could expose you to identity theft.

Feds OK’d Export of Millions of N95 Masks as U.S. Workers Cried for More

In the midst of a national shortage of N95 masks, the U.S. government quietly granted an exception to its export ban on protective gear, allowing as many as 5 million of the masks per month to be shipped overseas.

The Federal Emergency Management Agency issued the waiver in the final moments of Donald Trump’s presidency last month, allowing a Texas company to export its products after it failed to secure U.S. customers, according to the FEMA letter obtained by KHN.

National Nurses United president Zenei Triunfo-Cortez called the export waiver “unconscionable” and said N95s remain under lock and key in many hospitals. She said she still has to “beg” for a new N95 if hers gets soiled during a shift caring for covid-19 patients.

Health care employers “and a federal agency that is supposed to be protecting the people of America are not doing their jobs,” she said. “They have no regard for our safety.”

The disconnect between front-line workers going without better protection and federal officials suddenly exporting masks boils down to one thing, workplace-safety experts say: The government has not pivoted quickly enough to lift supply chain crisis-mode guidelines and force employers to take costly and sometimes cumbersome steps to better protect workers with top-quality gear.

The FEMA letter references the challenge that Fort Worth-based Prestige Ameritech faced in finding customers for its government-approved, high-end respirators: Hospitals did not want to “fit test” employees to its N95s, a 15-minute process per employee to ensure that a new N95 model seals to the face, according to company president Mike Bowen.

Prestige Ameritech’s Mike Bowen testifies before the House Energy and Commerce Subcommittee on Health hearing to discuss protecting scientific integrity in response to the covid pandemic on May 14, 2020. (Shaw Thew/AFP / Getty Images)

Bowen said he ramped up N95 production during the pandemic from 75,000 to 9.6 million per month. Lately, he said, he can’t sell them to major buyers, does not have the infrastructure to sell them to small buyers and has so many in storage that he may need to lay off workers and wind down production.

The FEMA letter references those challenges and says the waiver was granted in the “national defense interest” to ensure he keeps production running at pace. The letter was transmitted to Border Patrol officials who oversee exports 103 minutes before Joe Biden was sworn into office.

Yet even with the waiver, Bowen said, he hasn’t been able to find an overseas buyer. He said he can’t understand the contradictory information he’s getting: Front-line workers say they need more N95s, but hospitals say they don’t.

“There is a disconnect someplace, and I don’t know where it is,” Bowen said. “Why aren’t my phones ringing off the hook if there’s a shortage?”

A FEMA official said by email that the waiver could be revoked at any time if U.S. demand increases and that the agency could require the company to “satisfy domestic demand” before exporting N95s.

Although prices fall considerably for those buying in bulk, prices for smaller lots of N95s have reached $4 to $7 each, according to Get Us PPE, a nonprofit meant to match front-line workers with needed gear.

The requirement for employers to perform fit tests annually was set aside amid the public health emergency, giving employers little incentive to veer from the industry-standard models like 3M that were used for years. And the Centers for Disease Control and Prevention has left guidelines in place that say a limited cadre of health care workers should get N95s, which can be reused and rationed.

That adds up to an unusual situation in which U.S. mask supplies have surged, but employers’ motivation to buy the best protective gear has not, said Peg Seminario, a former union health and safety official who recently signed a letter urging the CDC to update its guidelines to reflect the risk of inhaling the virus.

“This is crazy,” she said. “We could … crush this pandemic where the biggest risks of infection are and we’re not doing it.”

Started by a group of emergency room doctors in March, Get Us PPE said it gets 89% of requests for gear — often N95s — from health workers outside of hospitals, like community clinics, covid testing sites and psychiatric care facilities. Demand rose throughout January, with 28% of front-line workers seeking N95s reporting that their site had none.

Yet the volunteer-run group has been able to fulfill only about 15% of the requests it receives. Dr. Ali Raja, a founder of the group and executive vice chair of the emergency department at Massachusetts General Hospital, said the need is vast outside of hospitals, but small facilities scrambling for gear are not connecting to bulk sellers like Bowen’s firm.

“There was nothing out there — no centralized place for all facilities to report PPE needs,” Raja said. “We don’t want to be the website with the best data on this. We want that to be the federal government.”

On the last day of 2020, FEMA extended its rule prohibiting anyone from exporting PPE, including N95s, without first getting express approval from the agency. The rule says the fall and winter surge in covid cases meant “domestic supply of the allocated PPE has not kept pace with demand and is not anticipated to do so.”

The U.S. Strategic National Stockpile has not yet met its goal for N95 respirators, according to a U.S. Government Accountability Office report. The report said that as of Dec. 18, there were 190 million N95 respirators in storage — well short of its goal of 300 million.

“GAO remains deeply troubled that agencies have not acted on recommendations to more fully address critical gaps in the medical supply chain,” the government watchdog report says.

Another twist to the saga is that millions of counterfeit N95s stamped “3M,” an industry standard that has long been used in previously required annual fit tests, have flooded hospital shelves even as federal agents rush to seize them at U.S. ports.

A prominent group of scientists wrote to the CDC on Monday to point out guidelines that urgently need to be changed to protect workers from inhaling tiny airborne virus particles. Their letter noted that the “CDC does not recommend the use of N95 respirators” outside health care settings, even though outsize risks are documented for bus drivers, prison guards and meatpacking staffers.

CDC guidelines also allow hospitals to limit which workers get the N95s, leaving out those in community settings and lower-level workers who typically spend the most time next to patients.

In the Lost on the Frontline project, KHN and The Guardian have documented the deaths of hundreds of more than 3,440 front-line health workers, of whom 2 in 3 were workers of color and 56% worked outside of hospitals. For more than 120 who died, family members had concerns about PPE, including the extensive reuse of N95s or the use of surgical masks for direct care of covid patients.

KHN senior correspondent JoNel Aleccia contributed to this report.

Journalists Field Questions on Covid Coverage

KHN Montana correspondent Katheryn Houghton discussed Thursday on Newsy how covid’s impact on disabled group housing isn’t tracked.

California Healthline senior correspondent Anna Maria Barry-Jester shared updates on California’s vaccine rollout on KALW’s “Your Call” on Thursday.

Related Topics

Public Health

To Vaccinate Veterans, Health Care Workers Must Cross Mountains, Plains and Tundra

A Learjet 31 took off before daybreak from Helena Regional Airport in Montana, carrying six Veterans Affairs medical providers and 250 doses of historic cargo cradled in a plug-in cooler designed to minimize breakage.

Even in a state where 80-mph speed limits are normal, ground transportation across long distances is risky for the Moderna mRNA-1273 vaccine, which must be used within 12 hours of thawing.

The group’s destination was Havre, Montana, 30 miles from the Canadian border. About 500 military veterans live in and around this small town of roughly 9,800, and millions more reside in similarly rural, hard-to-reach areas across the United States.

About 2.7 million veterans who use the VA health system are classified as “rural” or “highly rural” patients, residing in communities or on land with fewer services and less access to health care than those in densely populated towns and cities. An additional 2 million veterans live in remote areas who do not receive their health care from VA, according to the department. To ensure these rural vets have access to the covid vaccines, the VA is relying on a mix of tools, like charter and commercial aircraft and partnerships with civilian health organizations.

The challenges of vaccinating veterans in rural areas — which the VA considers anything outside an urban population center — and “highly rural” areas — defined as having fewer than 10% of the workforce commuting to an urban hub and with a population no greater than 2,500 — extend beyond geography, as more than 55% of them are 65 or older and at risk for serious cases of covid and just 65% are reachable via the internet.

For the Havre event, VA clinic workers called each patient served by the Merril Lundman VA Outpatient Clinic in a vast region made up of small farming and ranching communities and two Native American reservations. And for those hesitant to get the vaccine, a nurse called them back to answer questions.

“At least 10 additional veterans elected to be vaccinated once we answered their questions,” said Judy Hayman, executive director of the Montana VA Health Care System, serving all 147,000 square miles of the state.

The Havre mission was a test flight for similar efforts in other rural locations. Thirteen days later, another aircraft took off for Kalispell, Montana, carrying vaccines for 400 veterans.

In Alaska, another rural state, Anchorage Veterans Affairs Medical Center administrators finalized plans for providers to hop a commercial Alaska Airlines flight on Thursday to Kodiak Island. There, VA workers expected to administer 100 to 150 doses at a vaccine clinic conducted in partnership with the Kodiak Area Native Association.

“Our goal is to vaccinate all veterans who have not been vaccinated in and around the Kodiak community,” said Tom Steinbrunner, acting director of the Alaska VA Healthcare System.

VA began its outreach to rural veterans for the vaccine program late last year, as the Food and Drug Administration approached the dates for issuing emergency use authorizations for the Pfizer-BioNTech and Moderna vaccines, according to Dr. Richard Stone, the Veterans Health Administration’s acting undersecretary. It made sense to look to aircraft to deliver vaccines. “It just seemed logical that we would reach into rural areas that, [like] up in Montana, we had a contract with, a company that had small propeller-driven aircraft and short runway capability,” said Stone, a retired Army Reserve major general.

Veterans have responded, Stone added, with more than 50% of veterans in rural areas making appointments.

As of Wednesday, the VA had tallied 220,992 confirmed cases of covid among veterans and VA employees and 10,065 known deaths, including 128 employees. VA had administered 1,344,210 doses of either the Pfizer or Moderna vaccine, including 329,685 second vaccines, to veterans as of Wednesday. According to the VA, roughly 25% of those veterans live in rural areas, 2.81% live in highly rural areas and 1.13% live on remote islands.

For rural areas, the VA has primarily relied on the Moderna vaccine, which requires cold storage between minus 25 degrees Centigrade (minus 13 degrees Fahrenheit) and minus 15 degrees C (5 degrees F) but not the deep freeze needed to store the Pfizer vaccine (minus 70 degrees C, or minus 94 degrees F). That, according to the VA, makes it more “transportable to rural locations.”

The VA anticipates that the one-dose Johnson & Johnson vaccine, if it receives an emergency use authorization from the FDA, will make it even easier to reach remote veterans. The vaccines from Moderna and Pfizer-BioNTech both require two shots, spaced a few weeks apart. “One dose will make it easier for veterans in rural locations, who often have to travel long distances, to get their full vaccination coverage,” said VA spokesperson Gina Jackson. The FDA’s vaccine advisory committee is set to meet on Feb. 26 to review J&J’s application for authorization.

Meanwhile, in places like Alaska, where hundreds of veterans live off the grid, VA officials have had to be creative. Flying out to serve individual veterans would be too costly, so the Anchorage VA Medical Center has partnered with tribal health care organizations to ensure veterans have access to a vaccine. Under these agreements, all veterans, including non-Native veterans, can be seen at tribal facilities.

“That is our primary outreach in much of Alaska because the tribal health system is the only health system in these communities,” Steinbrunner said.

In some rural areas, however, the process has proved frustrating. Army veteran John Hoefen, 73, served in Vietnam and has a 100% disability rating from the VA for Parkinson’s disease related to Agent Orange exposure. He gets his medical care from a VA location in Canandaigua, New York, 20 miles from his home, but the facility hasn’t made clear what phase of the vaccine rollout it’s in, Hoefen said.

The hospital’s website simply says a staff member will contact veterans when they become eligible — a “don’t call us, we’ll call you,” situation, he said. “I know a lot of veterans like me, 100% disabled and no word,” Hoefen said. “I went there for audiology a few weeks ago and my tech hadn’t even gotten her vaccine yet.”

VA Canandaigua referred questions about the facility’s current phase back to its website: “If you’re eligible to get a vaccine, your VA health care team will contact you by phone, text message or Secure Message (through MyHealtheVet) to schedule an appointment,” it states. A call to the special covid-19 phone number established for the Canandaigua VA, which falls under the department’s Finger Lakes Healthcare System, puts the caller into the main menu for hospital services, with no information specifically on vaccine distribution.

For the most part, the VA is using Centers for Disease Control and Prevention guidelines to determine priority groups for vaccines. Having vaccinated the bulk of its health care workers and first responders, as well as residents of VA nursing homes, it has been vaccinating those 75 and older, as well as those with chronic conditions that place them at risk for severe cases of covid. In some locations, like Anchorage and across Montana, clinics are vaccinating those 65 and older and walk-ins when extra doses are available.

According to Lori FitzGerald, chief of pharmacy at the VA hospital in Fort Harrison, Montana, providers have ended up with extra doses that went to hospitalized patients or veterans being seen at the facility. Only one dose has gone to waste in Montana, she said.

To determine eligibility for the vaccine, facilities are using the Veterans Health Administration Support Service Center databases and algorithms to help with the decision-making process. Facilities then notify veterans by mail, email or phone or through VA portals of their eligibility and when they can expect to get a shot, according to the department.

Air Force veteran Theresa Petersen, 83, was thrilled that she and her husband, an 89-year-old U.S. Navy veteran, were able to get vaccinated at the Kalispell event. She said they were notified by their primary care provider of the opportunity and jumped at the chance.

“I would do anything to give as many kudos as I can to the Veterans Affairs medical system,” Petersen said. “I’m so enamored with the concept that ‘Yes, there are people who live in rural America and they have health issues too.’”

The VA is allowed to provide vaccines only to veterans currently enrolled in VA health care. About 9 million U.S. veterans are not enrolled at the VA, including 2 million rural veterans.

After veterans were turned away from a VA clinic in West Palm Beach, Florida, in January, Rep. Debbie Wasserman Schultz (D-Fla.) wrote to Acting VA Secretary Dat Tran, urging him to include these veterans in their covid vaccination program.

Stone said the agency does not have the authorization to provide services to these veterans. “We have been talking to Capitol Hill about how to reconcile that,” he said. “Some of these are very elderly veterans and we don’t want to turn anybody away.”

Companies Pan for Marketing Gold in Vaccines

For a decade, Jennifer Crow has taken care of her elderly parents, who have multiple sclerosis. After her father had a stroke in December, the family got serious in its conversations with a retirement community — and learned that one service it offered was covid-19 vaccination.

“They mentioned it like it was an amenity, like ‘We have a swimming pool and a vaccination program,’” said Crow, a librarian in southern Maryland. “It was definitely appealing to me.” Vaccines, she felt, would help ease her concerns about whether a congregate living situation would be safe for her parents, and for her to visit them; she has lupus, an autoimmune condition.

As the coronavirus death toll soars and demand for the covid vaccines dwarfs supply, an army of hospitals, clinics, pharmacies and long-term care facilities has been tasked with getting shots into arms. Some are also using that role to attract new business — the latest reminder that health care, even amid a global pandemic, is a commercial endeavor where some see opportunities to be seized.

“Most private sector companies distributing vaccines are motivated by the public health imperative. At some point, their DNA also kicks in,” said Roberta Clarke, associate professor emeritus of marketing at Boston University.

Among senior living facilities — which saw their largest drop in occupancy on record last year — some companies are marketing vaccinations to recruit residents. Sarah Ordover, owner of Assisted Living Locators Los Angeles, a referral agency, said many in her area are offering vaccines “as a sweetener” to prospective residents, sometimes if they agree to move in before a scheduled vaccination clinic.

Oakmont Senior Living, a high-end retirement community chain with 34 locations, primarily in California, has advertised “exclusive access” to the vaccines via social media and email. A call to action on social media reads: “Reserve your apartment home now to schedule your Vaccine Clinic appointment!”

Although the vaccine offer was a selling point for Crow, it wasn’t for her parents, who have not been concerned about contracting covid and didn’t want to forgo their independence, she said. Ultimately, they moved in with her sister, who could arrange home care services.

This marketing approach might sway others. Oakmont Senior Living, based in Irvine, reported 92 move-ins across its communities last month, a 13% increase from January 2020, noting the vaccine is “just one factor among many” in deciding to become a resident.

But some object to facilities using vaccines as a marketing tool. “I think it’s unethical,” said Dr. Michael Carome, director of health research at consumer advocacy group Public Citizen. While he believes that facilities should provide vaccines to residents, he fears attaching strings to a vaccine could coerce seniors, who are particularly vulnerable and desperate for vaccines, into signing a lease.

Tony Chicotel, staff attorney at California Advocates for Nursing Home Reform, worries that seniors and their families could make less informed decisions when incentivized to sign by a certain date. “You’re thinking, ‘I’ve got to get moved in in the next week or otherwise I don’t get this shot. I don’t have time to read everything in this 38-page contract,’” he said.

An Oakmont Senior Living advertisement touts access to covid vaccines to attract new residents.(Oakmont Management Group)

Oakmont Senior Living responded by email: “Potential residents and their families are always provided with the information they need to be confident in a decision to choose Oakmont.”

Some people say facilities are simply meeting their demand for covid vaccines. “Who is going to put an elderly person in a place without a vaccine? Congregate living has been a hotbed of the virus,” said retired philanthropy consultant Patti Patrizi. She and her son recently chose a retirement community in Los Angeles for her ex-husband for myriad reasons unrelated to the vaccines. However, they accelerated the move by two weeks to coincide with a vaccination clinic.

“It was definitely not a marketing tool to me,” said Patrizi. “It was my insistence that he needs it before he can live there.”

The concept of using vaccines to market a business isn’t new. The 2009 H1N1 pandemic ushered in drugstore flu shots, and pharmacies have since credited flu vaccines with boosting storefront sales and prescriptions. Many offer prospective vaccine recipients coupons, gift cards or rewards points.

A few pharmacies have continued these marketing activities while rolling out covid shots. On its covid vaccine information site, CVS Pharmacy encouraged visitors to sign up for its rewards program to earn credits for vaccinations. Supermarket and pharmacy chain Albertsons and its subsidiaries have a button on their covid vaccine information sites saying, “Transfer your prescription.”

But the pandemic isn’t business as usual, said Alison Taylor, a business ethics professor at New York University. “This is a public health emergency,” she said. Companies distributing covid vaccines should ask themselves “How can we get society to herd immunity faster?” rather than “How many customers can I sign up?” she said.

In an email response, CVS said it had removed the reference to its rewards program from its covid vaccination page. Patients will not earn rewards for receiving a covid shot at its pharmacies, the company said, and its focus remains on administering the vaccines.

Albertsons said via email that its covid vaccine information pages are intended to be a one-stop resource, and information about additional services is at the very bottom of these pages.

Boston University’s Clarke doesn’t see any harm in these marketing activities. “As long as the patient is free to say ‘no, thank you,’ and doesn’t think they’ll be penalized by not getting a vaccine, it’s not a problem,” she said.

At least one health care provider is offering complimentary services to people eligible for covid vaccines. Membership-based primary care provider One Medical — now inoculating people in several states, including California — offers a free 90-day membership to groups, such as people 75 and older, that a local health department has tasked the company with vaccinating, according to an email from a company spokesperson who noted that vaccine supply and eligibility requirements vary by county.

The company said it offers the membership — which entails online vaccine appointment booking, second dose reminders and on-demand telehealth visits for acute questions — because it believes it can and should do so, especially when many are struggling to access care.

While these may very well be the company’s motives, a free trial is also a marketing tactic, said Silicon Valley health technology investor Dr. Bob Kocher. Whether it’s Costco or One Medical, any company offering a free sample hopes recipients buy the product, he said.

Offering free trial memberships could pay off for providers like One Medical, he said; local health departments can refer many patients, and converting a portion of vaccine recipients into members could offer a cheaper way for providers to get new patients than finding them on their own.

“Normally, there’s no free stuff at a provider, and you have to be sick to try health care. This is a pretty unique circumstance,” said Kocher, who doesn’t see boosting public health and taking advantage of an uncommon marketing opportunity as mutually exclusive here. “Vaccination is a super valuable way to help people,” he said. “A free trial is also a great way to market your service.”

One Medical insisted the membership trial is not a marketing ploy, noting that the company is not collecting credit card information during registration or auto-enrolling trial participants into paid memberships. But patients will receive an email notifying them before their trial ends, with an invitation to sign up for membership, said the company.

Health equity advocates say more attention needs to be paid to the people who slip under the radar of marketers — yet are at the highest risk of getting and dying from covid, and the least likely to be vaccinated.

Kathryn Stebner, an elder-abuse attorney in San Francisco, noted that the high cost of many assisted living facilities is often prohibitive for the working class and people of color. “African Americans are dying [from covid] at a rate three times as much as white people,” she said. “Are they getting these vaccine offers?”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Spurred by Pandemic, Little Shell Tribe Fast-Tracks Its Health Service Debut

Linda Watson draped a sweater with the words “Little Shell Chippewa Tribe” over her as she received the newly recognized tribal nation’s first dose of covid-19 vaccine.

“I wanted to show my pride in being a Little Shell member,” Watson, 72, said. “The Little Shell are doing very good things for the people.”

Watson has diabetes and a heart condition. The shot brought some peace of mind during a time when that isn’t fully possible. One of her sons is among those who have died of covid.

The Little Shell Tribe of Chippewa Indians of Montana is building its health services largely from scratch roughly a year after becoming the United States’ 574th federally recognized Indigenous tribe. Because of the pandemic, it’s doing it on hyperdrive.

The long-sought recognition came just months before the pandemic took hold, arriving in time to guarantee the right to crucial health care and a tribal supply of protective covid vaccines. Federal pandemic relief dollars are speeding up the Little Shell Tribe’s ability to build its own clinic.

Without the CARES Act funds, Indian Health Service and Little Shell officials said it would have likely taken years using only IHS resources to establish a clinic. The IHS already has a list of new and replacement health care facility projects nationwide estimated to cost more than $14.5 billion, yet it reported in 2019 it receives roughly $240 million each year to get that work done. At that pace, it would take 60 years to get through its current needs.

Now, in Great Falls, roughly 2 miles from where Watson got her shot, a brick building under renovation bears a banner announcing the Little Shell Tribal Health Clinic: “Coming 2021.” The former animal hospital site that the tribe purchased will provide medical, dental, vision and behavioral care, alongside traditional medicine, a pharmacy and a lab. The goal is to open the clinic by late summer.

When Watson drives by the future clinic’s site on her way to work as the tribal nation’s enrollment officer, she said, she feels proud.

“To have a Little Shell name on it, to see the results of what our ancestors had worked so hard for,” Watson said. “It’s their descendants that are now experiencing it.”

The Little Shell have advocated for their place as a sovereign nation for more than 150 years. Although Montana formally recognized the tribe in 2000, not having federal recognition until December 2019 kept it from accessing many vital services and programs.

And without a recognized homeland, the tribe’s more than 5,700 members had scattered across Northern Plains states and Canada. The vast majority live in Montana.

Because of the federal recognition, Little Shell tribal enrollment has surged and its Ojibwe language course has a lengthening waitlist.

But this newfound strength is tempered by the deep challenges of the pandemic. The coronavirus has stalled in-person celebrations and planning in the tribe’s first year of federal recognition.

Worst yet, covid has disproportionately infected and killed Indigenous people nationwide, exposing long-standing health inequities caused by a history of colonization and underinvestment in Indian Country. In Montana, Native Americans make up roughly 7% of the population yet account for 11% of the state’s covid cases and 17% of related deaths.

The Little Shell tribal health care system is so new, it doesn’t have electronic health records set up and hasn’t tracked the statistics.

With a sweater bearing the words “Little Shell Chippewa Tribe,” Linda Watson receives the first dose of the tribe’s covid-19 vaccine supply. (Desarae Baker)

In October, the tribal nation hired its first health director, who had to create a covid vaccination plan while juggling other immediate needs, such as helping establish a transportation service for members to get to doctor appointments. Setting up infrastructure for a sovereign nation without a reservation presents challenges. The tribe’s service area encompasses four counties — Blaine, Cascade, Glacier and Hill — that together would span an area larger than Maryland. Only two of those counties share a border, so the distances are even greater.

Little Shell members now have access to any IHS facility nationwide, but, until their clinic is ready, some services such as dental and vision care are far-flung even for those close to the nation’s Great Falls headquarters.

“Without our clinic, members would have to drive 118 miles one way to get some basic services — and try doing that in January and February in Montana,” Tribal Chairman Gerald Gray said.

In the meantime, the tribe is partnering with the Cascade City-County Health Department to administer about 100 vaccine doses each week, according to the tribal health department. The effort has attracted tribal members from out of state.

Many questions remain as to how the new clinic will operate. Gray said the tribe has been told IHS will operate the clinic for at least three years before the tribal nation has the chance to completely run its services. Bryce Redgrave, the Billings-area IHS director, said in a statement the agency is discussing the possibilities but “no plan has been finalized at this time.”

Little Shell leaders plan to model the clinic after an Alaska Native-owned nonprofit called Southcentral Foundation that has been emulated by other tribes, including the Eastern Cherokee in North Carolina.

“The model is about treating the whole person and prioritizing Indigenous interventions,” said Little Shell tribal council member Kim McKeehan.

What that looks like for the Little Shell is still being decided, said Molly Wendland, the Little Shell tribal health director. She said one idea is to grow plants for traditional medicines behind the clinic. The tribe also plans to have a smudge room, she said, in which members can burn sage and ask for healing.

Linda Wilmore, 51, a Little Shell member who lives in Great Falls, said the new clinic would mean she wouldn’t put off care such as going to the dentist anymore. Without an option close to home, she said, she has often waited until she’s in enough pain to warrant the three-hour round trip to an IHS health care facility that offers dental care, where her insurance won’t leave her with unwieldy out-of-pocket costs.

She is also excited about having a clinic designed for, and by, the Little Shell Tribe. Growing up, Wilmore remembers her family having to ask permission to use IHS facilities in Montana before state recognition in 2000 guaranteed it.

“You felt like the redheaded stepchild asking, ‘We’re Little Shell, can we use your clinic?’” Wilmore said.

The Great Falls clinic will also fill gaps in care for other Indigenous people in nearby rural communities and the city itself.

Little Shell member Jonni Kroll lives about 50 minutes from an Indian Health Service clinic. She says the Little Shell tribe spread out largely because they weren’t federally recognized ― and now they’re playing catch-up to understand how to access the services ensured by that recognition. (Jessica Gerlett)

Little Shell members who live far from Great Falls are sorting through how to tap into newly granted services or how to access specialty treatment they can’t get at an IHS clinic.

Little Shell member Jonni Kroll, 55, lives in Deer Park, Washington, some 380 miles from the tribe’s future clinic. Her closest IHS alternative is a roughly 50-minute drive. Her first call was to book an eye appointment, only to find the clinic doesn’t have an optometrist.

“So then I go to the next clinic on my list,” Kroll said. “That’s a problem across the board with IHS nationwide, and I think that will affect Little Shell people trying to figure out: How do we utilize this when we are scattered?”

Little Shell people are spread out largely because they weren’t recognized, she noted, and now they’re having to play catch-up to understand how to access the services that recognition ensures. She said members, some of whom have never met, are connecting by phone or online to work through those questions together.

“The Little Shell are so resilient,” Kroll said. “We’ve gotten to the point of federal recognition and so now we find a way to come past that. There are lots of doors that opened, but we have a lot to learn.”

KHN’s ‘What the Health?’: Open Enrollment, One More Time

Can’t see the audio player? Click here to listen on SoundCloud.

An estimated 9 million Americans eligible for free or reduced premium health insurance under the Affordable Care Act have a second chance to sign up for 2021 coverage, since the Biden administration reopened enrollment on healthcare.gov and states that run their own marketplaces followed suit.

Meanwhile, Biden officials took the first steps to revoke the permission that states got from the Trump administration to require many adults on Medicaid to work or perform community service in exchange for their health coverage. The Supreme Court is scheduled to hear a case on the work requirements at the end of March.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Rachel Cohrs of Stat.

Among the takeaways from this week’s podcast:

  • The Biden administration said it will promote the special enrollment period, a stark change from the Trump administration, which dramatically limited funding for outreach. But navigator groups, whose workers help individuals find and sign up for coverage, say they haven’t yet heard whether the federal government will be offering to pay them to help people during this three-month sign-up period.
  • The House appears poised to pass a bill next week that would fund the covid relief measures President Joe Biden is seeking, as well as major changes to the ACA. Senate staffers are working with the House to align legislation from both chambers as much as possible. With little or no Republican support and only razor-thin majorities in both the House and Senate, Democrats will need to find common ground among their caucus to push the bill through.
  • Congress has a firm deadline on the covid relief bill since many current programs, such as the expanded unemployment funding, expire March 14.
  • CVS announced this week that its insurance subsidiary, Aetna, will be participating in the ACA marketplaces in the fall, another sign that those exchanges are growing in acceptance.
  • The Biden administration’s effort to walk back Medicaid work requirements appears to be an effort to head off the arguments at the Supreme Court. Democrats fear that even if they stop the program through administrative action now, a high-court ruling saying the effort was legal could open the door for future Republican administrations to restore work requirements.
  • The federal government is pushing hard to get more covid vaccine shots in arms around the country and last week reported that 1.7 million doses had been distributed. But it is a race against the emerging threat of covid virus variants, which are even more contagious than the original coronavirus.
  • Among hurdles in the vaccination effort is hesitancy among certain groups to get the shot. There have been reports that 30% of military personnel refused to accept the vaccine and some high-profile athletes in the NBA don’t want to be in public service announcements promoting it. Groups opposed to vaccines in general are posting misinformation online that may also be a source of concern.
  • The latest controversy over New York Gov. Andrew Cuomo’s policies on counting deaths among nursing home residents with covid-19 has consumed Albany and led to inquiries by legal authorities. It also raises questions about whether politics — Cuomo, a Democrat, and President Donald Trump regularly sparred about covid policies — influenced public health decisions.

Also this week, Rovner interviews medical student Inam Sakinah, president of the new group Future Doctors in Politics.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Stat’s “Hospitals’ Covid-19 Heroics Have Them Poised for Power in the New Washington,” by Rachel Cohrs

Rachel Cohrs: KHN’s “As Drug Prices Keep Rising, State Lawmakers Propose Tough New Bills to Curb Them,” by Harris Meyer; and Stat’s “States Still Can’t Import Drugs From Canada. Now, Many Are Seeking to Import Canadian Prices,” by Lev Facher

Alice Miranda Ollstein: Politico’s “How Covid-19 Could Make Americans Healthier,” by Joanne Kenen

Kimberly Leonard: The New Republic’s “The Darker Story Just Outside the Lens of Framing Britney Spears,” by Sara Luterman

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

El discurso anti inmigrante complica la vacunación contra covid en estados del sur

En el este de Tennessee, los médicos han visto de primera mano cómo una política de inmigración dura puede afectar la salud y el bienestar de una comunidad.

En 2018, agentes federales allanaron una planta empacadora de carne en Morristown, en el Valle de Tennessee, y detuvieron a unos 100 trabajadores sospechosos de ser indocumentados.

En las semanas siguientes, decenas de familias inmigrantes que habían encontrado trabajo en esas plantas buscaron santuario en las iglesias y dejaron de ir a las citas médicas.

¿La razón? Los agentes de inmigración estaban vigilando las clínicas.

“No queríamos que la gente viniera a recibir atención porque había oficiales de ICE en nuestro estacionamiento”, dijo Parinda Khatri, directora clínica de Cherokee Health Systems, un proveedor sin fines de lucro en el condado de Hamblen.

Mientras Tennessee, al igual que otros estados, se embarca en la abrumadora tarea de vacunar a millones de residentes contra covid-19, a muchos funcionarios de salud se les dificulta la tarea, por una desconfianza generalizada en el gobierno y las fuerzas del orden entre los inmigrantes sin papeles, una población estimada en 11 millones en todo el país.

Los desafíos son particularmente críticos en el sur, donde grandes poblaciones de inmigrantes indocumentados ayudan a mantener las prósperas industrias agrícola y de procesamiento de alimentos, incluso cuando muchos líderes republicanos estatales y locales, empoderados por la retórica antiinmigrante de la administración Trump, los denuncian como criminales y piden limitar su camino a la ciudadanía.

La confluencia de esas actitudes agresivas y un virus altamente contagioso ha generado preocupación en algunos estados: temen que la baja vacunación de indocumentados ponga en riesgo los esfuerzos para lograr la inmunidad colectiva.

“Nunca podremos superar esta pandemia si los indocumentados se quedan fuera”, dijo la doctora Sharon Davis, directora médica de la clínica comunitaria Los Barrios Unidos en Dallas, que atiende a 28,000 pacientes, la mayoría sin papeles.

Davis reconoció el desafío que plantea esto en un estado como Texas, donde la plataforma estatal del Partido Republicano pide la expulsión inmediata de todos los “extranjeros ilegales”. Como otros directores de clínicas en muchos estados del sur, Davis dijo que implementar planes de vacunación en las comunidades inmigrantes es una política de “don’t ask, don’t tell (“no preguntar, no decir”).

“Vivimos en Texas, así que ni lo mencionas”, agregó. “Hablamos de los que no tienen seguro, y hablamos de la población latina con la mayor morbilidad y mortalidad, es a quien estamos tratando de atender”.

En el área de Dallas-Fort Worth, hogar de una de las poblaciones más grandes de inmigrantes sin papeles de la nación, la tasa de muerte de los hombres latinos de mediana edad es ocho veces mayor que la de sus homólogos blancos no latinos.

Los epidemiólogos dicen que la disparidad no es sorprendente, dado que un gran número de trabajadores centro y sudamericanos indocumentados están en empleos considerados esenciales en la pandemia, incluido el trabajo agrícola, procesamiento de carne y servicio de alimentos, y la mayoría no tiene seguro médico.

Para agravar los riesgos, muchos trabajan en condiciones propicias para la propagación viral, parados hombro con hombro a lo largo de las cintas transportadoras en las empacadoras de verduras, lavando platos en las cocinas de los restaurantes, abasteciendo los estantes de los supermercados y limpiando habitaciones de hoteles.

Al final del día, muchos regresan a barracas o casas pequeñas que albergan a varias generaciones de familias.

“Si no trabajan, no comen”, dijo Davis. “Hemos tenido pacientes que nos suplican que no les hagamos la prueba, porque entonces no pueden ir a trabajar”.

Davis fue uno de los directores médicos que dijo que los sitios de vacunación masiva que muchos estados están usando (carpas gigantes con personal uniformado de la Guardia Nacional y personal médico con iPads) asustan a las familias inmigrantes.

“Preguntan ‘¿qué documentos tenemos que mostrar?’”, dijo Davis. “El miedo a la deportación es enorme y muy real”.

Y no es infundado, señalaron defensores, después de cuatro años en los que el ex presidente Donald Trump redujo drásticamente la inmigración legal e ilegal a través de detenciones y deportaciones masivas, prohibiciones de viaje y restricciones severas de asilo.

El presidente Joe Biden se ha comprometido a anular muchas de esas normas, pero defensores dicen que el apoyo a medidas más drásticas es fuerte entre algunos agentes de inmigración y agentes locales, lo que podría complicar la vida de muchos inmigrantes.

Davis agregó que, más allá del miedo al hostigamiento o al arresto, los funcionarios de salud pública están lidiando con información errónea. “Están escuchando historias horribles en las redes sociales”, dijo. “Creen que hay un microchip en la vacuna y que serán rastreados”.

Incluso algunos inmigrantes con papeles tienen reservas sobre recibir una vacuna proporcionada por el gobierno. La administración Trump presionó para descarrilar la ciudadanía de cualquier inmigrante que usara servicios públicos financiados por los contribuyentes, incluida la atención médica.

En diciembre, el Departamento de Justicia retiró la regla, pero hay confusión y los directores de las clínicas dicen que los pacientes darán prioridad a sus tarjetas de residencia por encima de casi todo.

Las bajas tasas de vacunación entre las poblaciones inmigrantes ya son evidentes. En Mississippi, por ejemplo, el Departamento de Salud informó que la semana del 8 de febrero se habían vacunado menos de 2,800 latinos, aproximadamente el 1% de todas las vacunas administradas hasta ahora.

Tennessee ofrece un excelente ejemplo de las tensiones que subyacen al lanzamiento de la vacuna.

El gobernador republicano, Bill Lee, fue noticia en mayo cuando permitió que el Departamento de Salud estatal compartiera con la policía los nombres y direcciones de quienes daban positivo para covid.

Por separado, el departamento de salud de la ciudad de Nashville proporcionó a la policía local las direcciones de las personas que daban positivo o que estaban en cuarentena.

Ambas acciones fueron criticadas y finalmente terminaron, pero Lee las defendió, diciendo que las eran apropiadas “para proteger las vidas de las fuerzas del orden” y que cumplían con las reglas federales de privacidad de la salud. Posteriormente, la ciudad buscó tranquilizar a sus “comunidades de inmigrantes diversas” diciendo que la información no se compartiría con las autoridades federales de inmigración.

Alabama, como Tennessee, tiene un historial de reglas estrictas con respecto a la inmigración, como una ley de 2011 que prohíbe que los inmigrantes sin papeles reciban casi todos los beneficios públicos, incluida la mayoría de la atención médica que no es de emergencia.

Velvet Luna, enfermera registrada de 26 años, ha construido su vida en Ozark, Alabama, una pequeña ciudad en Wiregrass, una región conocida por sus instalaciones de procesamiento de aves de corral y grandes poblaciones de inmigrantes hispanos y vietnamitas.

Luna se inscribió en el programa de Acción Diferida para los Llegados en la Infancia (DACA) una iniciativa de la era Obama que otorga estatus temporal a jóvenes indocumentados a los que trajeron al país de niños. Según el Centro Nacional de Leyes de Inmigración, casi 500,000 inmigrantes elegibles para DACA son trabajadores esenciales.

Luna, que habla con un suave acento sureño, solía hablar de su estatus migratorio, pero dijo que, en los últimos años, hombres que coqueteaban con ella cambiaban inmediatamente de actitud si sabían su estatus migratorio. “Decían cosas feas, hirientes, ‘Ustedes son la razón por la que nuestro país está en declive. Tienes que irte’”.

Como enfermera en un hospital del área que se ofreció como voluntaria para la unidad de covid, Luna ha recibido las dos dosis de la vacuna, pero entiende los riesgos que sopesan las familias indocumentadas; ninguno de sus padres, que vive cerca, tiene papeles. “Está bien tener miedo, y es una decisión valiente ir a vacunarse y proteger a tu familia”, dijo.

Incluso los opositores a la inmigración reconocen que la pandemia ha unido el destino de todos los que viven en el país, independientemente de cómo hayan llegado.

“Lo principal es vacunar a tantas personas como sea posible”, dijo Mark Krikorian, director ejecutivo del Centro de Estudios de Inmigración, un grupo conservador que aboga enérgicamente por restringir la inmigración. “Tu inmigración puede alcanzarte algún día, pero no será hoy”.

La administración Biden ha dicho que ICE no realizará operaciones en o cerca de los sitios de vacunación. “ICE no realiza ni llevará a cabo operaciones en o cerca de las instalaciones de atención médica, como hospitales, consultorios médicos, clínicas de salud acreditadas e instalaciones de atención de emergencia o urgencias, excepto en las circunstancias más extraordinarias”, según una declaración del Departamento de Seguridad Nacional del 1 de febrero.

Los comisionados estatales de salud también han tratado de calmar los nervios. “No le negamos la vacuna a nadie que se presente en nuestros sitios y esté en la fase que se está vacunando”, dijo la doctora Lisa Piercey, comisionada del Departamento de Salud de Tennessee. “Este es un recurso federal, y si estás en este país, tienes una vacuna”.

Los defensores, sin embargo, dijeron que persisten obstáculos para convencer a los inmigrantes de que la información no se utilizará en su contra. Los Centros para el Control y la Prevención de Enfermedades (CDC) esperan que los proveedores que administran las vacunas carguen la información del paciente en los registros estatales, incluido TennISS en Tennessee o ImmTrac2 en Texas.

Los sistemas de seguimiento permiten a los proveedores asegurarse de que los pacientes regresen para su segunda dosis e identificar cualquier reacción adversa.

Los proveedores tratan de explicar que esta información se usa para iniciativas de salud, no para inmigración.

“Los pacientes, en particular los de origen inmigrante, son muy sensibles a compartir detalles familiares”, escribió Brian Haile, director ejecutivo de Neighborhood Health, una clínica comunitaria en Nashville, a funcionarios de salud de Tennessee en diciembre. “Si les pedimos que proporcionen esta información a proveedores que no conocen, serán aún más reticentes a vacunar a sus familias”.

En el condado de Hamblen, Khatri dijo que está tratando de persuadir a trabajadores en granjas de tomate y tabaco, y en plantas procesadoras de carne, zonas calientes de brotes de coronavirus, de que confíen en su clínica no solo para administrar la vacuna sino también para manejar datos confidenciales.

“Quieren acudir a un grupo de confianza”, dijo Khatri, cuyas clínicas tienen la aprobación para distribuir la vacuna, pero aún no han recibido ninguna dosis.

Helena Lobo, quien coordina el alcance hispano en Cherokee Health, dijo que, para algunos inmigrantes, la elección puede estar entre su salud o permanecer ocultos.

“Si tienen que arriesgar su estatus migratorio para recibir la vacuna contra covid, no la tendrán. No los culpo”, dijo Lobo. “Se preguntan: ‘¿Cuál es mi mayor riesgo? ¿Ser deportado o tener covid?’”.

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Family Caregivers, Routinely Left Off Vaccine Lists, Worry What Would Happen ‘If I Get Sick’

Robin Davidson entered the lobby of Houston Methodist Hospital, where her 89-year-old father, Joe, was being treated for a flare-up of congestive heart failure.

Before her stretched a line of people waiting to get covid-19 vaccines. “It was agonizing to know that I couldn’t get in that line,” said Davidson, 50, who is devoted to her father and usually cares for him full time. “If I get sick, what would happen to him?”

Tens of thousands of middle-aged sons and daughters caring for older relatives with serious ailments but too young to qualify for a vaccine themselves are similarly terrified of becoming ill and wondering when they can get protected against the coronavirus.

Like aides and other workers in nursing homes, these family caregivers routinely administer medications, monitor blood pressure, cook, clean and help relatives wash, get dressed and use the toilet, among many other responsibilities. But they do so in apartments and houses, not in long-term care institutions — and they’re not paid.

“In all but name, they’re essential health care workers, taking care of patients who are very sick, many of whom are completely reliant upon them, some of whom are dying,” said Katherine Ornstein, a caregiving expert and associate professor of geriatrics and palliative medicine at Mount Sinai’s medical school in New York City. “Yet, we don’t recognize or support them as such, and that’s a tragedy.”

The distinction is critically important because health care workers have been prioritized to get covid vaccines, along with vulnerable older adults in nursing homes and assisted living facilities. But family members caring for equally vulnerable seniors living in the community are grouped with the general population in most states and may not get vaccines for months.

The exception: Older caregivers can qualify for vaccines by virtue of their age as states approve vaccines for adults ages 65, 70 or 75 and above. A few states have moved family caregivers into phase 1a of their vaccine rollouts, the top priority tier. Notably, South Carolina has done so for families caring for medically fragile children, and Illinois has given that designation to families caring for relatives of all ages with significant disabilities.

Arizona is also trying to accommodate caregivers who accompany older residents to vaccination sites, Dr. Cara Christ, director of the state’s Department of Health Services, said Monday during a Zoom briefing for President Joe Biden. Comprehensive data about which states are granting priority status to family caregivers is not available.

Meanwhile, the Department of Veterans Affairs recently announced plans to offer vaccines to people participating in its Program of Comprehensive Assistance for Family Caregivers. That initiative gives financial stipends to family members caring for veterans with serious injuries; 21,612 veterans are enrolled, including 2,310 age 65 or older, according to the VA. Family members can be vaccinated when the veterans they look after become eligible, a spokesperson said.

“The current pandemic has amplified the importance of our caregivers whom we recognize as valuable members of Veterans’ health care teams,” Dr. Richard Stone, VA acting undersecretary for health, said in the announcement.

An estimated 53 million Americans are caregivers, according to a 2020 report. Nearly one-third spend 21 hours or more each week helping older adults and people with disabilities with personal care, household tasks and nursing-style care (giving injections, tending wounds, administering oxygen and more). An estimated 40% are providing high-intensity care, a measure of complicated, time-consuming caregiving demands.

This is the group that should be getting vaccines, not caregivers who live at a distance or who don’t provide direct, hands-on care, said Carol Levine, a senior fellow and former director of the Families and Health Care Project at the United Hospital Fund in New York City.

Rosanne Corcoran, 53, is among them. Her 92-year-old mother, Rose, who has advanced dementia, lives with Corcoran and her family in Collegeville, Pennsylvania, on the second floor of their house. She hasn’t come down the stairs in three years.

“I wouldn’t be able to take her somewhere to get the vaccine. She doesn’t have any stamina,” said Corcoran, who arranges for doctors to make house calls when her mother needs attention. When she called their medical practice recently, an administrator said they didn’t have access to the vaccines.

Corcoran said she “does everything for her mother,” including bathing her, dressing her, feeding her, giving her medications, monitoring her medical needs and responding to her emotional needs. Before the pandemic, a companion came for five hours a day, offering some relief. But last March, Corcoran let the companion go and took on all her mother’s care herself.

Corcoran wishes she could get a vaccination sooner, rather than later. “If I got sick, God forbid, my mother would wind up in a nursing home,” she said. “The thought of my mother having to leave here, where she knows she’s safe and loved, and go to a place like that makes me sick to my stomach.”

Although covid cases are dropping in nursing homes and assisted living facilities as residents and staff members receive vaccines, 36% of deaths during the pandemic have occurred in these settings.

Maggie Ornstein, 42, a caregiving expert who teaches at Sarah Lawrence College, has provided intensive care to her mother, Janet, since Janet experienced a devastating brain aneurism at age 49. For the past 20 years, her mother has lived with Ornstein and her family in Queens, New York.

In a recent opinion piece, Ornstein urged New York officials to recognize family caregivers’ contributions and reclassify them as essential workers. “We’re used to being abandoned by a system that should be helping us and our loved ones,” she told me in a phone conversation. “But the utter neglect of us during this pandemic — it’s shocking.”

Rosanne Corcoran (right) and her mother, Rose, at Rose’s 80th birthday party in 2008. Rose now has advanced dementia and lives with Corcoran and her family. Corcoran hopes to get the vaccine but has been unable to yet. “If I got sick, God forbid, my mother would wind up in a nursing home,” she says. (Daniel Francis)

Ornstein estimated that if even a quarter of New York’s 2.5 million family caregivers became ill with covid and unable to carry on, the state’s nursing homes would be overwhelmed by applications from desperate families. “We don’t have the infrastructure for this, and yet we’re pretending this problem just doesn’t exist,” she said.

In Tomball, Texas, Robin Davidson’s father was independent before the pandemic, but he began declining as he stopped going out and became more sedentary. For almost a year, Davidson has driven every day to his 11-acre ranch, 5 miles from where she lives, and spent hours tending to him and the property’s upkeep.

“Every day, when I would come in, I would wonder, was I careful enough [to avoid the virus]? Could I have picked something up at the store or getting gas? Am I going to be the reason that he dies? My constant proximity to him and my care for him is terrifying,” she said.

Since her father’s hospitalization, Davidson’s goal is to stabilize him so he can enroll in a clinical trial for congestive heart failure. Medications for that condition no longer work for him, and fluid retention has become a major issue. He’s now home on the ranch after spending more than a week in the hospital and he’s gotten two doses of vaccine — “an indescribable relief,” Davidson said.

Out of the blue, she got a text from the Harris County health department earlier this month, after putting herself on a vaccine waitlist. Vaccines were available, it read, and she quickly signed up and got a shot. Davidson ended up being eligible because she has two chronic medical conditions that raise her risk of covid; Harris County doesn’t officially recognize family caregivers in its vaccine allocation plan, a spokesperson said.

Anti-Immigrant Vitriol Complicates Vaccine Rollout in Southern States

In eastern Tennessee, doctors have seen firsthand how a hard-line immigration policy can affect the health and well-being of a community.

In 2018, federal agents raided a meatpacking plant in Morristown, a manufacturing hub in the Tennessee Valley, and detained nearly 100 workers they suspected of being in the country illegally. In the weeks that followed, scores of immigrant families who had found work in the meat-processing plants dotting broader Hamblen County scrambled to find sanctuary in churches — and scrupulously avoided seeking medical care.

The reason? Immigration agents were staking out clinics.

“We did not want people to come in for care because there were ICE officers in our parking lot,” said Parinda Khatri, chief clinical officer at Cherokee Health Systems, a nonprofit provider in Hamblen County.

As Tennessee, like other states, embarks on the daunting task of inoculating millions of residents against covid-19, many health officials find their mission complicated by a pervasive mistrust of government and law enforcement among unauthorized immigrants, a population estimated at 11 million across the U.S.

The challenges are particularly acute in the South, where large populations of immigrants living there illegally help maintain the region’s thriving agricultural and food-processing industries even as many state and local Republican leaders, emboldened by the Trump administration’s four years of anti-immigrant vitriol, denounce unauthorized residents as criminals and call for more limited paths to citizenship.

The confluence of those aggressive attitudes and a highly contagious virus has prompted concerns in some states that lackluster vaccination of people in the country without legal permission will short-circuit efforts to achieve herd immunity for the broader community.

“We will never get on top of this pandemic if the undocumented are left out,” said Dr. Sharon Davis, chief medical officer at Los Barrios Unidos Community Clinic in Dallas, which serves 28,000 patients, the majority of them in the country without authorization.

She acknowledged the challenge that poses in a state such as Texas, where the state Republican Party platform calls for the immediate expulsion of all “illegal aliens.” Echoing clinic directors in many Southern states, Davis said rolling out vaccination plans in immigrant communities is a “don’t ask, don’t tell” policy.

“We live in Texas, so you don’t bring it up. You don’t mention it,” she said. “We talk about the uninsured, and we talk about the Latinx population with the highest morbidity and mortality — that’s who we’re trying to serve.”

In the Dallas-Fort Worth area, home to one of the nation’s largest populations of unauthorized immigrants, the covid death rate for middle-aged Latino men is eight times higher than for their non-Latino white counterparts.

Epidemiologists say the disparity is not surprising, given vast numbers of Central and South American workers in the country illegally are doing jobs deemed essential in the pandemic, including farm labor, meat-processing and food service, and most have no health insurance.

Compounding the risks, many of these workers labor in conditions ripe for viral spread, standing shoulder to shoulder along conveyor belts in vegetable-packing houses, washing dishes in restaurant kitchens, stocking grocery shelves and cleaning hotel rooms. At day’s end, many return to bunkhouses or cramped homes housing multiple generations of family.

“It’s going through the whole house, and if the whole house doesn’t work, they don’t eat,” Davis said. “We’ve had patients begging us not to test them, because then they can’t go to work.”

Davis was among the medical directors who said the mass vaccination sites many states are using in the rollout — giant tents staffed by uniformed National Guard troops and iPad-toting medical personnel — have spooked immigrant families.

“They are asking, ‘What documentation do we have to show at the mass vaccination sites?’” said Davis. “Fear of deportation is just huge, and very real.”

And not unfounded, advocates noted, coming off four years in which former President Donald Trump sharply curtailed both legal and illegal immigration through mass detention and deportation, travel bans and severely restricting asylum. President Joe Biden has pledged to undo many of Trump’s policies, but immigrant advocates say support for more drastic measures runs strong among some immigration agents and local law enforcement officers, who could make life difficult for immigrants they suspect are in the country illegally.

Beyond fear of harassment or arrest, Davis said, public health officials are dealing with misinformation, including widespread rumors about government surveillance efforts secreted in the vaccine. “They are hearing horrible stories on social media,” she said. “They believed there was a microchip in the vaccine and they would be tracked.”

Even some immigrants living in the U.S. legally have reservations about receiving a government-provided vaccine. The Trump administration pushed to derail citizenship for any immigrant who used taxpayer-funded public services, including health care. In December, the Department of Justice withdrew the rule, but confusion abounds, and clinic directors say patients will prioritize their green cards above almost all else.

Sluggish vaccination rates among immigrant populations are already apparent. In Mississippi, for example, the Department of Health reported last week that fewer than 2,800 Latinos have been vaccinated — about 1% of all vaccinations administered so far.

Tennessee offers a prime example of the tensions underlying the vaccine rollout.

The Republican governor, Bill Lee, made headlines in May when he allowed the state Department of Health to share the names and addresses of those who tested positive for the virus with police. The city of Nashville’s health department separately provided local police with the addresses of people who tested positive or were quarantining.

Both efforts came under criticism and eventually ended, but Lee defended the effort, saying the information was “appropriate to protect the lives of law enforcement” and permitted by federal health privacy laws. The city later sought to reassure its “diverse immigrant communities” that the information would not be shared with federal immigration authorities.

Alabama, like Tennessee, has a history of tough rules regarding immigration, including a sweeping 2011 law that bars unauthorized immigrants from receiving nearly all public benefits, including most nonemergency medical care.

Velvet Luna, a 26-year-old registered nurse, has built her life in Ozark, Alabama, a small city in the Wiregrass, a region known for its poultry-processing facilities and large populations of Hispanic and Vietnamese immigrants. Luna enrolled in Deferred Action for Childhood Arrivals, or DACA, an Obama-era program that granted temporary status to unauthorized immigrants brought across the border as children. According to the National Immigration Law Center, nearly 500,000 DACA-eligible immigrants are essential workers.

Luna, who speaks with a soft Southern accent, once freely shared her immigration status, she said, but in recent years men who flirted with her “would find out my status and they would immediately change their attitude toward me. They would say ugly, ugly, hurtful things. ‘You are the reason our country is declining. You need to get out of here.’”

As a nurse at an area hospital who volunteered in the covid unit, she has received both doses of vaccine, but she understands the risks undocumented families weigh; neither of her parents, who live close by, are authorized to be in the U.S. “It’s OK to be scared, and it’s a courageous move to go get the vaccine and protect your family,” she said.

Even hard-line immigration opponents acknowledge the pandemic has tied together the fates of everyone living in the U.S., regardless of how they arrived.

“The main thing is to get shots into as many people’s arms as possible,” said Mark Krikorian, executive director of the Center for Immigration Studies, a conservative think tank that strenuously advocates for restricting immigration. “Your immigration may catch up with you someday, but that’s not today.”

The Biden administration has said U.S. Immigration and Customs Enforcement will not conduct enforcement operations at or near vaccine distribution sites. “ICE does not and will not carry out enforcement operations at or near health care facilities, such as hospitals, doctors’ offices, accredited health clinics, and emergent or urgent care facilities, except in the most extraordinary of circumstances,” according to a Feb. 1 statement issued by the Department of Homeland Security.

State health commissioners also have tried to calm rattled nerves. “We are not denying vaccine to anyone who shows up at our sites and is in a phase,” said Dr. Lisa Piercey, commissioner of the Tennessee Department of Health. “This is a federal resource, and if you’re in this country, then you get a vaccine.”

Advocates, however, said hurdles remain in convincing wary emigres that the personnel information collected as part of the vaccination process will not be used against them. The Centers for Disease Control and Prevention expects providers administering covid vaccines to upload patient information to state registries, including TennISS in Tennessee or ImmTrac2 in Texas. The tracking systems allow providers to ensure patients return for their second dose, and to identify any adverse reactions.

The use of such information for health initiatives, not immigration crackdowns, is a nuance that providers struggle to explain.

“Patients, particularly those of immigrant origin, are highly sensitive to sharing family details,” Brian Haile, executive director of Neighborhood Health, a community clinic in Nashville, wrote to Tennessee health officials in December. “If we ask them to provide this information to providers they do not know, they will be even more reticent to have their families get vaccinated.”

In Hamblen County, Khatri said she’s trying to persuade those laboring on tomato and tobacco farms and in meat-processing plants — hot zones of coronavirus outbreaks — to trust her clinic not only to administer the vaccine but also to handle sensitive data.

“They want to go to a trusted group,” said Khatri, whose clinics have received approval to distribute the vaccine but have not yet received any doses.

Helena Lobo, who coordinates Hispanic outreach at Cherokee Health, echoed that, saying, for some immigrants, the choice may come down to choosing their health or choosing to remain hidden.

“If they have to risk their immigration status to have the covid vaccine, they will not have it. I don’t blame them,” said Lobo. “They go by risk: ‘What is my biggest risk? Being deported or to have covid?’”

Vaccines Go Mobile to Keep Seniors From Slipping Through the Cracks

ANTIOCH, Calif. — A mobile “strike team” is bringing vaccines to some of Northern California’s most vulnerable residents along with a message: This is how you avoid dying from covid-19.

So far, that message has been met with both nervous acceptance and outbursts of joy from a population that has been ravaged by the disease. One 68-year-old pastor, who lives in a racially diverse, low-income senior housing complex, rolled down his sleeve after his shot and said he wants to live to see 70 — just to spite the government.

The team of county nurses and nonprofit workers is targeting Contra Costa County residents who are eligible for covid vaccines but have been left out: residents of small assisted-living facilities that haven’t yet been visited by CVS or Walgreens, and occasionally people who live in low-income senior housing. The retail pharmacy giants have a federal government contract to administer vaccines in most long-term care facilities.

Launched a few weeks ago, the strike team moves through each vaccination clinic with practiced choreography. At a small group home in Antioch recently, a nurse filled syringes while another person readied vaccine cards and laid them on a table. An administrative assistant — hired specifically for these clinics — checked everyone’s paperwork and screened them for symptoms and allergies before their shots, logging them into the state’s database afterward. After the shots, a strike team member told each person when their 15 minutes of observation was up.

The mobile strike team in Contra Costa County pulls up to a senior apartment complex in Richmond, California. Its members tote a special cooler to keep vaccines cold, syringes, bandages and a roll of “just vaccinated” stickers. (Rachel Bluth/KHN)

In a little over an hour, 14 people had a shot in their arm, a card in their hand and their data in the system. Nurses wiped down the chairs and tables and packed up supplies.

As the state vaccination plan moves past long-term care facilities and on to the next group, deploying mobile units will help prevent eligible people in small facilities from being left behind, said Dr. Mike Wasserman, past president of the California Association of Long Term Care Medicine.

“The assisted living side has been our greatest tragedy,” Wasserman said. “It’s February. We’re vaccinating others already and we haven’t finished vaccinating those who need it most.”

California is in the midst of transferring primary control of vaccine distribution from local public health departments to Blue Shield of California. The agreement between the state and the insurance company includes incentives for vaccinating underserved and minority populations, and like Contra Costa, Los Angeles, Kern and other counties are creating mobile clinics to reach vulnerable residents.

But as efficiently as these clinics can run, it’s still slow going to vaccinate a few people at a time in a state that has lost more than 44,500 people to covid.

Small long-term care facilities, usually with no more than six beds, are the strike team’s main target. These “six-beds” are a major source of residential care for older Californians, as well as others who need care and supervision but don’t want to live in nursing homes. Of almost 310,000 long-term care beds in California, about one-third are in nursing homes, according to Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties. Two-thirds are in some form of assisted living, mostly six-beds.

In the converted garage of a six-bed long-term care facility in Antioch, California, public health nurses ready doses of covid vaccine for staffers and residents. Once the vials are pulled from the freezer, the nurses have six hours to administer doses before they expire. Alarms on the nurses’ phones ring each hour, indicating it’s time to log the temperature of the cooler. (Rachel Bluth/KHN)

These homes are typically in residential areas, with little to distinguish them from other houses on a suburban block. They’re small businesses, often owned by families, that offer a “social” model of care, not a medical one. There is no doctor or director of nursing on staff.

Long-term care residents were in line to be vaccinated right after front-line health workers, starting in nursing homes. Theoretically, residents of small facilities like six-beds should get their shots from the same federal program vaccinating most nursing homes, which is administered through CVS and Walgreens.

But it’s difficult to coordinate with these homes because there are so many, Howell explained, and they often have fewer resources and minimal IT infrastructure. Because these aren’t large corporate chains or 500-bed facilities with everyone’s medical records on hand, it takes time and local knowledge to reach them all, she said.

Catherine Harris, 72, gets her first dose of covid vaccine in the community room of a low-income senior housing complex in Richmond, California. She got her shot from a mobile vaccine team that visits Contra Costa County’s vulnerable residents. (Rachel Bluth/KHN)

CVS and Walgreens said they have administered first and second doses to nearly all nursing home residents in the state and have started on assisted living communities. They said they do not have breakdowns of which kinds of assisted living facilities they have visited, but CVS Health spokesperson Joe Goode noted that the pharmacy has completed the first round of doses at nearly 80% of participating assisted living facilities, with hundreds more clinics scheduled.

The state has largely left it up to facilities to call the pharmacies to schedule clinics, though many did not know it was their responsibility until late January, according to Mike Dark, a lawyer with California Advocates for Nursing Home Reform. He had been fielding calls for weeks from families who were told that, if they wanted to get their loved ones in six-bed homes vaccinated, they needed to figure it out themselves, he said.

“Smaller assisted living facilities, the ones least equipped to deal with this virus, still house people with significant impairment and needs,” Dark said. “It’s been a scandal, really, how poorly this process has been going.”

Robert Ellison, 86, receives his vaccine card during a vaccine clinic at his low-income apartment building in Richmond, California. He and William Patterson, 83, spent their 15-minute post-vaccination observation period out on the patio. (Rachel Bluth/KHN)

The residents at Above All Care, a six-bed in Orange County, finally got their first shots on Feb. 4, according to owner Nicolas Oudinot. But that came after weeks of confusion and silence.

“From November to mid-January, I had no information,” Oudinot said. “I went from nothing to getting a call every day. They tried to schedule the same facility two or three times.”

In late December, when it became clear that many long-term care facilities wouldn’t get clinics scheduled for months, Contra Costa County decided the federal program needed to be supplemented with local resources, said Dr. Chris Farnitano, the county health officer.

“This is where we’re seeing the most dying happening,” Farnitano said. “These are the most vulnerable people. We’ve got to protect them sooner.”

The mobile vaccine strike team emerged from a collaboration among the county, local home health agencies, advocates for long-term care residents and nonprofit groups. It was created without additional public funding when Choice in Aging, a local nonprofit that provides community-based support to older residents, paid its own administrative workers to staff the clinics alongside county public health nurses.

The team of five or six people heads out several days a week, hauling rolling carts packed with syringes, bandages and a special vaccine cooler. The team might spend one day vaccinating 100 people in six-bed and other small facilities for older people or those with disabilities. The next, it might visit 50 seniors and their caregivers gathered from a few low-income apartments.

Christina Ponce, a public health nurse for Contra Costa County, fills syringes with the Pfizer-BioNTech vaccine. She can almost always squeeze six doses out of each vial. (Rachel Bluth/KHN)

The vaccines are treated like a precious resource. Nothing goes to waste and there’s a list of caregivers on standby if the team finds itself with extra shots. Nurses say they can almost always squeeze a sixth dose of what they call “liquid gold” out of the vials, intended to contain five.

When defrosted vials aren’t in the cooler, they’re carried gingerly, sandwiched between two egg cartons so they don’t tip or break. Often, the team’s biggest problem is running too far ahead of schedule.

Its efforts seem to be working: 810 people in 50 facilities had been vaccinated as of Tuesday.

Choice in Aging CEO Debbie Toth said she originally got into this line of work to give people a choice of where to spend their last years. But the pandemic has given her work new urgency: saving lives.

“These are people who would die” if they got covid, she said. “We have an opportunity to make sure they don’t. That’s our north star.”

California Healthline correspondent Angela Hart contributed to this report.

Can Pfizer and Moderna End the Pandemic by Sharing Their Vaccine Designs? It’s Not that Simple

“Pfizer and Moderna could share their design with dozens of other pharma companies who stand ready to produce their vaccines and end the pandemic.”

— Feb. 3 in a Facebook post

Vaccine makers Pfizer and Moderna earned praise for creating highly effective covid-19 vaccines in record time. But are they inadvertently hurting the public by not sharing their technology with other pharmaceutical companies to help speed up vaccine manufacturing and distribution?

That’s what one post circulating on social media claims.

“The vaccine shortage doesn’t need to exist,” reads an image of a tweet shared thousands of times on Facebook. “Pfizer and Moderna could share their design with dozens of other pharma companies who stand ready to produce their vaccines and end the pandemic.”

In short, the situation is not that simple. The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed. (Read more about PolitiFact’s partnership with Facebook.)

The tweet doesn’t mention that the two drugmakers are already partnering with other companies to produce the vaccine. It also makes it appear as if dozens of companies are regulated to make vaccines and have a ready supply of the raw materials, equipment and storage needed to efficiently and effectively produce them. Experts say that’s not the case.

When PolitiFact reached out to the tweet’s author, Dr. James Hamblin, a public health policy lecturer at Yale University and writer at The Atlantic, he acknowledged that using the words “stand ready” in the tweet inaccurately implied the process could begin immediately.

“It takes time and investment to begin making mRNA vaccines,” Hamblin told PolitiFact. “The companies would need the assurance that they not lose money by getting into that space, possibly in some way similar to the assurances given during the research phase of warp speed.” 

Vaccine Technology Narrows the Field

Both Pfizer and Moderna’s vaccines rely on newer messenger RNA technology. (It has been studied for some time but hasn’t been used in a vaccine until now.) The mRNA is fragile and needs to be handled carefully, with specific temperatures and humidity levels to keep it from breaking down. 

It’s highly unlikely, experts say, that “dozens” of manufacturing plants have the capability to get this type of production off the ground immediately. Even if Pfizer-BioNTech and Moderna made their vaccine designs open source today, pharmaceutical researchers estimate, it would still take several months for other companies to produce the shots, and by then mass distribution and inoculation will be well underway. 

PolitiFact reached out to both companies for comment but did not hear back.

Dr. Rajeev Venkayya, president of the Global Vaccine Business Unit at Takeda Pharmaceuticals and former director of vaccine delivery at the Bill & Melinda Gates Foundation’s Global Health Program, wrote a Twitter thread addressing the complexity and risk of vaccine manufacturing.

Among many other issues, Venyakka said, vaccines are complex biologics and it’s hard to predict whether changes to the manufacturing process will affect the vaccines’ effectiveness or safety.

“Many vaccines are made by growing viruses in cells, and when that doesn’t happen as expected, it can lead to losses in production and delayed timelines. This is an area where cell- and virus-free mRNA vaccine production has a major advantage,” Venkayya wrote

“For these reasons, every aspect of vaccine manufacturing is tightly controlled: raw materials, equipment, production processes, training, operating procedures etc. All of it happens under GMP [good manufacturing practice] regulations, and facilities are regularly inspected.” 

According to the Food and Drug Administration, manufacturers may share any information or data about their products they choose, as they are the owners of the information. But the company is responsible for ensuring that any contract manufacturer is in compliance with the FDA’s good manufacturing practice regulations.

These rules establish minimum requirements for the methods, facilities and controls used in making and packing pharmaceuticals. They aim to ensure that a product is safe for use and that it has the ingredients and strength it claims to have.

Existing Partnerships Are Already Speeding Production

John Grabenstein, associate director for scientific communications at the Immunization Action Coalition, a vaccine information organization that works in partnership with the Centers for Disease Control and Prevention, told PolitiFact the tweet wrongly presumes that the companies aren’t already outsourcing production. Grabenstein tracks partnerships between pharmaceutical companies and contract manufacturers. 

He said Pfizer-BioNTech is working with biopharmaceutical companies Rentschler and Polymun, while Moderna has partnered with RoviRecipharm and Lonza. Some of the companies are located exclusively overseas, while others have plants in the U.S. 

Typically, the contractors are doing one of the major portions of production, Grabenstein said, such as manufacturing the bulk product, formulation of the bulk into the final preparation, filling the drug product into vials, or finishing the final packaging, which could include labeling vials, inserting them and paperwork into boxes, and assembling boxes for a carton.

For example, Rovi, one of the companies working with Moderna, signed a contract in July to start filling and packaging 100 million doses of the vaccine in early 2021.

In fewer cases, a full-fledged manufacturer is commissioned to make a mirror image of the original product, from start to finish. 

One example of this is the Serum Institute of India — the world’s largest vaccine manufacturer — which is already producing a parallel version of the Oxford-AstraZeneca vaccine that the institute will market with the trade name CoviShield. The institute launched the construction of new facilities in June to make that happen. The organization recently announced a similar partnership with Novavax

“This is incredibly intricate and the number of facilities and trained personnel is really, really small,” Grabenstein said. “It’s not like you’re just giving a recipe to another restaurant. That ‘recipe’ is thousands and thousands of pages long, and then you have to validate and show that you meet all the really tight performance specifications and prove consistency of process before any of the regulators will let you distribute any of the vaccine.”

Hamblin, the author of the Twitter post, said it’s unlikely the companies would share their vaccine designs, given the current system of intellectual property and funding, though he noted exceptions, like Sanofi.

Sanofi, a French multinational pharmaceutical company, announced in January that it had entered into a partnership with BioNTech, the company that co-developed the vaccine with Pfizer. Sanofi said it will provide the company access to its “established infrastructure and expertise to produce over 125 million doses of COVID-19 vaccine in Europe.” Initial supplies will originate from Sanofi’s production facilities in Frankfurt, Germany, this summer.

Hamblin noted that if vaccine makers open the intellectual property in a permanent, unconditional way — rather than on a small scale for a finite period — it could help get more companies and governments into the production “in a more permanent, cost-effective way.” 

“If we have to manufacture boosters in specific areas for new strains, for example, or for the next coronavirus, we could be on it right away,” Hamblin said. “Again, speaking hypothetically about that — not implying it will happen or would be quick or easy or anything else.”

Defense Production Act Allows Greater Collaboration But Takes Time

With President Joe Biden invoking the Defense Production Act, couldn’t that serve to help speed things up? Yes, but the law is not as sweeping as some think. 

The Defense Production Act of 1950 gives presidential authority to promote national defense by expediting and expanding the supply of materials and services from the U.S. industrial base.

Dr. George Siber, a vaccine expert on the advisory board of CureVac, a German mRNA vaccine company, told KHN that invoking the act would allow the government to commandeer an appropriate plant to expand production, but that it would still take about a year to get going.

Companies would first have to undertake a thorough cleaning of their equipment and facilities to prevent cross-contamination and would need to set up, calibrate and test equipment, and train scientists and engineers to run it, Siber told KHN.

“Do you want glass? Aluminum? Filter resins? What is the thing that you need?” Grabenstein said. “For example, vaccine manufacturers say, ‘If only I had more glass vials, I could increase my weekly production.’ OK, the government gets you more glass vials. Then it reveals the next bottleneck.”

He added: “Is there production that could be stopped or delayed, and let those machines be used for this goal? Sure, but you still have to clean it, and quality-control that it’s really clean, and then the transfer and validation of process. It’s months or years of commitment. This is not turn-on-a-dime kind of stuff.” 

According to the CDC, nearly 66 million doses of the Moderna and Pfizer-BioNTech vaccines had been distributed and roughly 45 million administered by the second week in February.

The U.S. has vaccinated about 10% of the population, putting it about sixth in the world, according to a tracker maintained by The New York Times

Our Ruling

A post claims the covid-19 vaccine shortage doesn’t need to exist because Pfizer and Moderna can share their vaccine designs with “dozens” of other pharmaceutical companies that are ready to produce the vaccines and end the pandemic.

This premise oversimplifies the vaccine manufacturing process.

First, the post doesn’t mention that Pfizer-BioNTech and Moderna already have partnerships with various contract manufacturers to help speed up vaccine production. Second, industry experts say it’s highly unlikely “dozens” of pharmaceutical companies that aren’t already producing the vaccines stand ready to do so. Supplies, personnel training and facility compliance are just a few aspects that make the process complex and lengthy.

So, while such partnerships are clearly an asset to rapid vaccine production, they are not entirely practical in the grand sense that this tweet implies.

The statement contains an element of truth but ignores critical facts that would give a different impression. We rate it Mostly False.

Source List:

Facebook post, Feb. 3, 2021

Science Magazine, “Myths of Vaccine Manufacturing,” Feb. 2, 2021

KHN, “Why Even Presidential Pressure Might Not Get More Vaccine to Market Faster,” Jan. 26, 2021

Twitter, Dr. Rajeev Venkayya thread, Feb. 1, 2021 

Centers for Disease Control and Prevention, “COVID-19 Vaccinations in the United States,” accessed Feb. 8, 2021

The New York Times, “Tracking Coronavirus Vaccinations Around the World,” accessed Feb. 8, 2021

PolitiFact, “State of Vaccine Supply Is ‘Opaque,’ ‘Hard to Pin Down,’ Experts Say, Feb. 4, 2021 

Modernatx.com, “Moderna and ROVI Announce Collaboration for OUS Fill-Finish Manufacturing of Moderna’s COVID-19 Vaccine Candidate,” July 9, 2020

Food and Drug Administration, “Current Good Manufacturing Practice (CGMP) Regulations,” updated Sept. 21, 2020 

Message from Dr. James Hamblin, Feb. 8, 2021

Phone interview, John Grabenstein, associate director for scientific communications for the Immunization Action Coalition, Feb. 5, 2021

Email interview, Alison Hunt, spokesperson for the Food and Drug Administration, Feb 5. 2021

In Search of the Shot

Too little covid vaccine and too great a demand: That’s what KHN readers from around the country detail in their often exasperating quest to snag a shot, although they are often clearly eligible under their local guidelines and priority system. Public health officials say the supply is growing and will meet demand in several months, but, for now, readers’ experiences show how access is limited. Some savvy readers report no problem getting in line for the vaccine, but others say that balky application processes and lack of information have stymied their efforts. Their unedited reports are a good snapshot of the mixed situation around the country.

— Feb. 12 —

I’m 65 and eligible for the vaccine. But I belong to an independent medical group, and many of the big vaccinators here are big medical groups. When I call my doctor, he tells me that they are waiting for a clinic, that he has no vaccine. The touted “mass vaccination site” at Cal Expo is barely used. When I hear there’s vaccine available at various hospitals, pharmacies and clinics, when I log on there are no appointments available. It’s vaccine for the privileged and members of the big medical groups. Everyone else loses out.

— 65-Year-Old
Sacramento, California

— Feb. 12 —

I am trying to get my 86-year-old mother vaccinated in Manhattan, NYC. Aside from the shortage, I am very angry at the hospitals and other vaccination sites for their horrible, inconsiderate websites, which are making the anxiety worse. Very simple things could be done to make them kinder. At present, you end up going in circles. For example: NorthwellHealth’s facilities are near her apartment. After going to the NYC covid page, I select one of their hospitals and click to their site. When they do not have any vaccine, they have no information on their covid page about 1st vaccine appointments. None. There is a button for making appointments, which leads you to making regular appointments with doctors. There should be a big button on the page you land on from the NYS listing that says MAKE A VACCINATION APPOINTMENT, even if there are no appointments. Some of the other sites make you fill out the forms before telling you that there are no vaccines. And you can’t just do it once. You have to do it over and over again. 

My sister and I are trying to do this for her. The fact that you MUST go thru the internet is pushing the elderly, those who need the vaccine the most, to periphery. But, at least, they could make the websites friendly and helpful. We’re a country where we spend more money and time making sure people know how to drink coke than they do helping people understand healthcare. This is a systematic problem that should be improved. There are marketing people out there who know how to interact with the public, but the healthcare system chooses not to use them.

— New York

Yesterday I experienced the good and the bad of the vaccine rollout.  My 95-year-old mother endured a one hour, twenty minute ordeal mostly standing outside 380 W MacArthur Kaiser in Oakland, thankfully a wheelchair was offered and very much appreciated.

We were there 15 minutes early for the 10:15 appt. and finished at 11:20. The whole operation seemed clunky and bureaucratic, think of standing in a long line at a rental car company.

Now to my almost dreamlike experience gliding through the Moscone Center in SF, arriving about 25 minutes early for my 5:45 appt. I was immediately checked in and escorted to the vaccination booth, the nurse checked me out on her screen asked me the routine questions jabbed my arm gave me my 5:45 sticker and sent me to observation area.  After my morning in Oakland I’d love to take my mom to Moscone for her second shot but as far as I can tell Kaiser doesn’t seem to allow that.

— Oakland, California

I’m a stage 4 cancer survivor and may have long-term heart and lung effects from the treatments I went through. I’m 44 and live in Denver. It’s unclear which vaccine group I fall into. Some states, such as New York, prioritize any cancer survivor, but Colorado only considers people who have been in treatment for the past month. Also, they want you to have two high-risk conditions — how are those defined? Do I qualify? Do my doctors have any input on that?

My oncologist and my primary care doctor have no word on when I might get vaccinated. My health system’s website says if you have an online account, you’re already in their system and they will inform you when you’re eligible. I do not know if that takes into account my medical history.

I’ve been to four pharmacies so far in my area; only one has had vaccines, and they did have a list on paper to call if they wound up with extras. I also signed up online with a couple of health care systems (Centura, National Jewish) for notifications; only one asked about medical conditions upon sign-up.

So, at this rate, I’m guessing: spring? Summer? Will I be treated as a healthy adult and be the last vaccinated?

— 44-Year-Old

Checked the Sacramento County website on Feb. 3. Found a link to a vaccination clinic at our neighborhood Safeway. Made an appointment for Feb. 6, at which time I received my first dose. Within minutes of being vaccinated, I received an email confirming an appointment for the second dose in 28 days.

— Sacramento, California

We heard the local center would allow people to sign up at 3 p.m. on a Sunday. My husband and I were refreshing our respective computers every five seconds waiting for the portal to open. We snagged appointments via EventBrite on the same day, same hour. When my husband and I went for our first shot, we stood in line for roughly 1½ hours outside, in the sun and heat, before we got inside the county health office, which administered the shot. Most of the other people in line were older and/or frail, with walkers and in wheelchairs. The county staff did their best to make them comfortable, which wasn’t much due to the logistics of the operation. The second shot was a breeze — in and out in about 25 minutes, including the mandatory 15-minute wait after the inoculation. I have a friend who is 80 years old, a three-time cancer survivor, and still can’t get an appointment and has tried numerous times.

— Lakewood Ranch, Florida

I signed up with the Kalamazoo County Health Department in Michigan. It was just a couple of weeks, I think, before they sent the application to sign up for the appointment. I had a choice of two days and three time spans with first, second and third choice and was asked if I needed any assistance. I then was emailed an appointment. When I got there, a policeman was directing traffic and giving instructions to stay in the car until five minutes before my appointment. It seemed less. I went through several stops very fast. The parking lot had so many cars and I had to wait 30 minutes after my injection. And, still, in 45 minutes I was driving down the street and also had my second appointment made. 

They reminded me days before my appointment, the day before my appointment and the morning of my appointment. So fast, so efficient and so many people there that there was no time to do anything but get done what had to be done. AMAZING planning and amazing workers and volunteers.

— 77-Year-Old
Kalamazoo, Michigan

Maryland covid distribution is a true mess. There is no central registration site. The state has a site that lists many providers, most of which do not have the vaccine. One of the large statewide vaccine sites, Six Flags America, does not allow you to sign up for the vaccine. Almost all the sites listed on the state’s website indicated they do not have the vaccine.

— 68-Year-Old
Ellicott City, Maryland

It’s terrible here in the county for Tier 2. That includes all the educators and everyone over 70. The appointment software company they chose to use did nothing to change their program to account for thousands daily and hourly trying to get an appointment.

I eventually was able to get my first shot. I still was not able to use the information that the Carson City Health and Human Services was putting in the news. I noodled around on the internet and discovered a notice that a drugstore (Walgreens) and a drugstore within a supermarket (Smith’s Food and Drug) were being sent the Moderna vaccine and were taking appointments starting the next day. I tried Walgreens but I don’t shop there and could not enter its system. I tried Smith’s, and it was so simple anyone could get on it. I made an appointment so easily for the next morning. Four days ago, I received an email from Kroger, the parent company of Smith’s, telling me the day and time for my second dose. 

Each city, county and state seem to have surprisingly different ways of putting out information, where and how the vaccine is delivered and administered. I do think it is still a logistics issue that was not anticipated by our former government officials.

— 78-Year-Old
Carson City, Nevada

I signed up for a vaccine several weeks ago with the county health department. I’m 78, living in Albuquerque. My registration was acknowledged but nothing further. The county program appears to be in chaos.

— 78-Year-Old
Albuquerque, New Mexico