Using Data to Track COVID-19 Vaccine Uptake and Target Hesitant Communities

As COVID-19 vaccines hit the market across the world, countries had to grapple with how to get doses to people, which required setting up prioritization, reducing disparities, and targeting communities using data from the first months of the vaccine rollout. During a session at Virtual ISPOR 2021, speakers from Israel and the United States explained the situation on the ground, while a speaker from Johnson & Johnson tackled the broad challenge of equity of COVID-19 vaccine distribution.

With approximately 60% of the population fully vaccinated, Israel is ahead of most other countries, said Ruth Waitzberg, MA, PhD candidate, researcher at Myers-JDC-Brookdale Institute. In comparison, the United States only has 37% of its population fully vaccinated, according to the latest CDC data. Broken down by age group, individuals 70 years and older are almost entirely vaccinated, and the 40- to 70-year age group is more than 80% vaccinated.

The country was able to achieve these high rates of vaccination because it collaborated with Pfizer to determine if herd immunity can be achieved after reaching a certain percentage of vaccination coverage. Israel provided Pfizer with anonymized aggregated epidemiological data about the residents and Pfizer provided enough doses to vaccinate the entire country.

“Having enough doses allowed for a simple prioritization policy,” Waitberg said. The country prioritized based on wide age groups, and because there were enough doses, Israel quickly opened up to other age groups without having to wait for the previous age group to be fully vaccinated. Within 40 days of rollout, the entire population over the age of 16 years could be vaccinated.

But having enough doses wasn’t enough: The country needed people willing to get the dose. Since Israel started its vaccination campaign in December 2020, it had the additional challenge of having no real-world data to point to. At the time, only the clinical trial data were available. To improve compliance and reduce hesitancy, the country took multiple steps:

• Launched an awareness campaign to fight fake news
• Promoted expert opinion on vaccine safety and scientific data from well-known and respected figures
• Provided daily updates on vaccination coverage by age group and locality
• Publicized images of well-known people, such as political and religious leaders and celebrities, getting the vaccine
• Improved access in remote areas with mobile vaccination units
• Made school reopenings dependent on morbidity and vaccination rates at the municipal or neighborhood levels

Vaccination uptake was slower among some communities, such as the ultraorthodox Jewish and Arab communities, and it took 2 months to convince them to start getting the vaccine, according to Waitzberg. The campaigns targeting these 2 communities:

• Used messages culturally adapted in Yiddish and Arabic that cited phrases from the Bible or well-known Arab proverbs to incentivize people
• Set up special desks staffed by people in the communities
• Provided comfort food at pop-up vaccination sites
• Implemented a coordinator for apartment buildings to encourage vaccination by facilitating transportation and finding child care solutions

In addition to cultural minorities, vaccination rates were lower among young people, so Israel sent mobile vaccination units to places where young people were congregating. But what might have been the ultimate incentive, according to Waitzberg, was the creation of the Green Pass, an official document issued 7 days after the second vaccine dose or recovery from COVID-19 that grants access to indoor university buildings, cultural and sport events and venues, restaurants, and hotels.

The Green Pass is not without controversy. Children are not eligible to get the vaccine, and as such cannot get a Green Pass. This means families with children cannot eat indoors at restaurants or go to venues that require the Green Pass. There is also the ethical problem being raised by workplaces mandating employees show their Green Pass when they come to work, Waitzberg explained.

Information and data were very powerful tools to help Israel reach its high levels of vaccination, she said.

“When we have more evidence about the safety and efficacy [of COVID-19 vaccines], it encourages people [to get the vaccine], at least in Israel, where, when they started the rollout there was almost no info about real-world rollout,” Waitzberg said. “It was very important for [people] to see the first results.”

The next speaker provided a look at the vaccine rollout at a more local level. David Bishai, MD, PhD, professor at Johns Hopkins Bloomberg School of Public Health, is the health officer of Harford County in Maryland. Traditionally a health economist, he took on a job in local government. “Now I don’t have to convince a policy maker on how to run a health system, I just have to convince myself,” he joked.

In his county, the health department had to set up a number of partnerships in order to successfully rollout the vaccine. Local knowledge was important for gaining the trust of residents and provided insight into vulnerable communities, such as minorities and shut-in seniors, he said.

“We know who can get things done,” he said. “We know how to really reach out to the local groups here. We sort of burrowed into the African American and Hispanic community.”

In Harford County, and the rest of the United States, the priority groups were (in order) nursing home residents, medical and emergency medical service workers, seniors aged 75 and older and teachers, and seniors aged 65 and older.

As the county rolled out vaccines, it got off to a slow start, as just the first 2 priority groups were eligible and production of vaccines was still ramping up. In the peak week, the county delivered 12,000 shots. However, when the mass vaccination sites were set up, they were overstaffed, according to Bishai. Although the Ripken Stadium site was staffed to offer 15,000 doses per week, at its peak, it was providing just 2000 doses a week.

“So, there were a lot of waste built into the system due to an inability to forecast demand at these large sites,” he said.

Once the county was providing vaccines, it collected data that highlighted which communities need more targeted outreach to improve vaccination rates. According to Bishai, there were 2 pockets with lower vaccination rates: one in the south that was largely Black and one in the north that was largely very conservative Republicans.

The state used the data to target these communities by sending a pop-up unit to the north and set up question-and-answer sessions with the Black community, as well as set up church-based pop-ups. Although there was a racial gap at the beginning of the vaccine rollout, with a 2:1 ratio of White to Black individuals getting the vaccine in February, that gap was closed over time due to the measures the county put in place.

Currently, the coverage for Black and White female seniors is identical, Bishai said, although Black men over the age of 65 are 86% as vaccinated compared with their White counterparts. Overall, the county is about 45% vaccinated, which is nowhere near herd immunity.

“But I've really lost my hope that we will reach herd immunity this year,” Bishai said. “The people resisting are dug in, and it's not like you'd have to tell them some magic scientific statement. It's part of their personal identity to be unvaccinated.”

Finally, Brahim Bookhart, MBA, MPH, head of Real-World Value and Evidence – Vaccines, Infectious Disease, Cardiovascular and Metabolics, at Johnson & Johnson, discussed health equity related to the COVID-19 virus and vaccine distribution. Research showed that there were certain communities disproportionately affected by the virus: Blacks, Hispanics, Alaska Natives, American Indians, Native Hawaiians, and Pacific Islanders. These communities also face social and structural factors and comorbid conditions that put that at a higher risk, he said.

Although it’s controversial, Bookhart thought these vaccines maybe should have been rolled out by race, “because there was clear evidence that there was a disproportionate burden in certain communities.”

Some factors that affect equitable distribution are:

• Efficacy/effectiveness data
• Safety data
• Dosing frequency
• Cost
• Storage
• Duration of protection
• Transmission of disease post vaccination

Globally, there have been differences in how vaccines have been rolled out, with countries with the highest incomes getting vaccinated 25 times faster than countries with the lowest income. The 27 wealthiest countries and regions only have 10.5% of the world’s population, but 34.8% of vaccinations.

In the United States, the vaccination rates range widely: from 50% in Vermont to just 26% in Mississippi. Similar to what Bishai reported, Bookhart noted that the vaccination rates among the Black/Hispanic population have lagged behind the White population. While 41 states/cities have vaccinated 30% or more of the White population, only 11 and 13 states have done as well with the Hispanic and Black populations, respectively.

Part of the reason for the different rates of vaccination is how the vaccines were rolled out, Bookhart explained. The Hispanic population tends to be younger with more children, which will skew their vaccination numbers. But the other factor among communities of color is trust.

“You have a history there in terms of trust and certainly that's being magnified in terms of adoption and vaccine hesitancy,” Bookhart said. “So, those are things that we need to think about. Certainly, some of the solutions to [the trust issue] call for better and more complete data on race and ethnicity.”