From offers for free beer to cash incentives, states are taking new approaches to encourage more people to vaccinate against COVID-19. The moves are a stark indicator of how demand for the vaccine has significantly decreased in recent weeks.
While the incentives have generated attention, the interest could be short-lived. Healthcare stakeholders say a more substantial and sustainable approach would be to shift the focus of current vaccination strategies from mass vaccination sites to increasing access within primary and outpatient care.
"They need to integrate it into routine care," said Dr. Scott Ratzan, distinguished lecturer at the City University of New York's Graduate School of Public Health. "I think just routinizing it into the primary care setting will make a huge difference."
Ratzan is the lead author of an article published Wednesday in the New England Journal of Medicine that contended the emphasis on large vaccination sites in the pandemic has led to fewer Americans getting shots in places they normally receive care, creating a missed opportunity to reach those who are still hesitant about getting the vaccine.
As supplies of COVID-19 vaccine have surpassed demand, Ratzan said the effort to reach unvaccinated adults will rely more on the ability of clinicians to have conversations with their patients about the benefits of taking the vaccine while alleviating their safety concerns.
"We still have to remind people the threat of COVID is real", Ratzan said. "But we also need to tailor messages that resonate differently with people of different ages, different cultural, religious, ethnic and political backgrounds — we need ongoing efforts that address the needs of people to get vaccinated and to keep appropriate preventive measures."
As of May 6, more than 147 million adults have received at least one dose of a COVID-19 vaccine, according to the Centers for Disease Control and Prevention, which accounts for 57% of the total U.S. adult population.
But recent trends indicate the country has entered into a new, more challenging phase of the vaccine rollout compared to its early months. At the beginning of February, the country had already reached the point where more Americans had received at least one dose of the vaccine than the number of individuals who were testing positive for the virus. Demand for the vaccine was so high it took some people weeks to find an available site and schedule an appointment.
But the average number of doses administered has rapidly dropped in recent weeks. Total doses administered fell from a high of 3.4 million a day on April 13 to 2.1 million on May 6, according to figures from the University of Oxford.
As part of the NEJM study, Ratzan analyzed survey results of more than 138,000 people who checked in online for regular medical visits between March 4 and March 31, which found 60% of those adults reported they were unvaccinated.
Yet the analysis also found only about 11% of adults said they were unvaccinated because they were resistant to getting the vaccine. More than one-third of unvaccinated adults surveyed said they were either avidly seeking to get vaccinated or were receptive to getting vaccinated if it was readily available during a medical visit.
Overall, one in six unvaccinated adults who responded to the survey said they were more inclined to get the vaccine if it was recommended by their healthcare provider.
"There's a certain percentage of people that we're never going to get," study co-author Dr. Joseph Cacchione, executive vice president of clinical and network services for St. Louis-based health system Ascension. "What we need to do is to get people who are indifferent or just a bit hesitant — if we can convert them we can get much closer to herd immunity in a shorter period of time."
While Cacchione acknowledged the continued need for the mass vaccination sites, he said Ascension has started to transition its vaccination strategy to make it more accessible within more routine care settings. Doses of Johnson and Johnson's single-shot vaccine are available within all Ascension clinics. Three mobile units are regularly deployed to deliver vaccines to more vulnerable populations, like the homeless. Those efforts have led to the distribution of more than 1 million vaccine doses across 20 states.
"That's a huge impact that we can have, especially in the more vulnerable patient populations," Cacchione said.
Madison, Wis.-based, UW Health has taken a similar approach. Dr. Matt Anderson, senior medical director of primary care at UW Health, said last week marked the first time the health system didn't fill all of its vaccination appointments since it started administering shots.
He said vaccinations would continue to be available at their mass vaccination sites but the system will use more targeted approaches too. Healthcare personnel are visiting communities to partner with organizations on identifying and reducing barriers to vaccination. The health system also recently re-allocated some of its resources from mass vaccination sites to follow up with individuals who missed second dose appointments and get them the needed shots.
Much of the health system's focus has been on figuring out ways to get more vaccinations within their regular clinic structures. One big challenge is all but 1,000 of UW Health's vaccine doses are from Pfizer and BioNTech, which requires storage in specialized, ultra-cold freezers that can to reach temperatures of below minus 76 degrees Fahrenheit
Anderson said he hopes recent changes to Wisconsin's vaccine allocation request process will allow the health system to order more of Johnson and Johnson's one-shot vaccine, which can be stored in standard refrigerators.
"It's really kind of a three-pronged approach that focuses on increased mobility, outreach and getting it [vaccine] into the clinics," Anderson said of UW Health's plan.
Ratzan said it will likely take a combination of various approaches, which include mass vaccinations, incentive programs, and possibly mandates, for the U.S. to reach its goal of vaccinating 70% of the population in order to achieve herd immunity.
For the long term, experts feel moving vaccinations into primary care settings can provide the kind of ease of access that will be needed if vaccinating for coronavirus becomes an annual public health precautionary measure, similar to seasonal flu shots.
"If we do need to have the booster for an ongoing effort, we don't want to continue to have to have big stadiums or convention centers, we need to integrate vaccine into healthcare," Ratzan said. "That's a better place for them to be because people will trust them more."
