By Frances Stead Sellers, Lenny Bernstein, Lena H. Sun and Kayla Ruble,
For The Washington Post
Pat Dunaj, 77, has rarely left her Michigan home in the past two years and was slated to receive the Johnson & Johnson coronavirus vaccine — until regulators paused its use. (Nic Antaya for The Washington Post)
Homebound with severe lung disease, 77-year-old Pat Dunaj worked her phone and the Internet until she secured a promise from the county health department to come to her door with a shot of Johnson & Johnson’s coronavirus vaccine last week.
Federal officials then paused the use of the vaccine, followed by the inevitable call from the county that Dunaj’s April 13 vaccination had been canceled.
“They wouldn’t give it to me. They didn’t know what to do. So they erred on the side of caution,” said Dunaj, who lives in Livingston County, Mich.
Now, the plan is to vaccinate her Friday with a dose of Moderna vaccine, though that will mean another visit to Dunaj’s home 28 days later for a second shot.
Reaching out to the homebound, the homeless, the hesitant and those who have trouble accessing vaccines is part of the next big push in the U.S. vaccination effort, which so far has relied largely on mass vaccination sites, drugstores and clinics. The J&J pause makes that effort more difficult, by delaying vaccinations for people like Dunaj, who were easier to reach with the one-dose vaccine. It is also forcing some health care providers to switch to the more cumbersome Moderna and Pfizer-BioNTech products, which require two doses, are harder to transport and need to be stored at ultracold temperatures.
The pause, undertaken after six J&J vaccine recipients developed rare, severe blood clots, comes at the same time as the overall number of doses being administered each day is falling. That suggests the country’s remaining unvaccinated adults are less interested or less able to head out to get the shot.
“Basically, it’s really important that we have multiple platforms to promote vaccination that include community distribution, pharmacies, also doctors’ offices,” said former Centers for Disease Control and Prevention director Tom Frieden. He said if coronavirus vaccines are to be available in primary care settings, it is far easier if they can be administered once, like a flu shot.
Dunaj, who lives in a mobile home park in Hartland, Mich., is tethered to an oxygen tank 24 hours a day because of chronic obstructive pulmonary disease.
Dunaj said she has not been out of her home for any significant length of time since the middle of 2019. Everything she needs is brought to her. She sees her pulmonologist over Zoom.
“We had a visiting physician, but when the covid hit, they stopped,” she said. She is happy to get the Moderna shot, which will reduce the risk she will acquire covid-19 from any of her caregivers, or pass it on to them.
Setbacks are to be expected in any vaccine program and can typically be accommodated, according to Kelly Moore, deputy director of the Immunization Action Coalition. But clinicians who had embarked on efforts to reach isolated individuals worry about the pause — particularly as mutations and new pockets of infection increase the urgency of the race against the virus.
In Maine, the grocery chain Hannaford was relying exclusively on Johnson & Johnson. “They are THE grocery chain, and a lot of people who may not have been so keen on getting a vaccine anywhere else would get it if Hannaford is doing it,” said Nirav Shah, director of Maine’s Center for Disease Control and Prevention.
“This pause, it cuts our through put in half,” Shah said. Maine is receiving about 3,000 fewer doses of all coronavirus vaccines this week than it did last week.
The most hard hit group are migrant farmworkers scattered throughout the state. The state’s mobile clinic had vaccinated 58 blueberry farmworkers in the rural eastern part of the state. It had plans to vaccinate dairy workers and then travel to inoculate potato packers working along the U.S.-Canada border, said Lisa Tapert, chief executive of the Maine Mobile Health Program, which operates the federally qualified health center as an all-mobile clinic.
Although the numbers are small, the workers live and work in crowded conditions, putting them at higher risk for infection.
In Texas, a family-owned pharmacy based in Austin has stepped in to fill a gap in services for people with intellectual and developmental disabilities and their caregivers. Tarrytown Pharmacy works with this community to provide medication, and some families reached out for help with accessing the coronavirus vaccine, said Rannon Ching, pharmacy manager at Tarrytown’s flagship store.
Use of Johnson & Johnson’s coronavirus vaccine was paused when rare cases of blood clots were identified in a handful of the 7.5 million people in the United States who had received the shot. (Dado Ruvic/Reuters)
Tarrytown has administered about 13,000 doses to people living in group homes or in foster care using the Johnson & Johnson vaccine, Ching said. It was also supposed to vaccinate about 6,000 athletes for Special Olympics Texas and had planned a clinic for 600 to 700 people on April 13.
“I woke up that morning and saw the news and we had to cancel the clinic,” recalled Ching. The state was able to supply the pharmacy with doses of Moderna, so the pharmacy and Special Olympics scrambled to contact families to let them know there would still be a vaccination clinic.
In the next few weeks, the pharmacy staff will be returning to 15 cities around Texas to give the second doses.
Ching said some people who signed up to get J&J declined to get the Moderna shot.
“They said they only wanted the J&J shot, and they said they wanted to wait and see what happens with Johnson and Johnson,” Ching said.
Richard Bates, regional vice president of medical affairs at MidMichigan Health, said a single-dose shot is preferable in circumstances when the second shot is hard to administer.
“It’s nice to just have one and done,” Bates said.
Bates’s program to vaccinate the homebound, which traded away doses of Pfizer/BioNTech and Moderna to increase their allocation of Johnson & Johnson, succeeded in vaccinating 51 people in 4 counties during its first run in late March.
Among them was Janet Cochran, an 80-year-old retiree, who got a J&J shot sitting at her kitchen table in rural Ogemaw County.
“I was happy because I was wondering what I was going to do to get this done,” Cochran said, explaining that she had difficulty figuring out where to go.
Bates’s last stop that day was to vaccinate 83-year-old Helen Duncan, who is blind and lives alone.
“You know, any time I can have something done in my home it is so convenient for me,” said Duncan, who wasn’t concerned when she later learned about the pause.
“I’m not losing any sleep over it,” she said, believing the large number of coronavirus cases in Michigan is far more worrying.
Bates is more concerned. His home visits are on hiatus until a decision is made about the Johnson & Johnson vaccine. The success of his program reflects a growing body of evidence that doctors are trusted when it comes to choosing to be vaccinated — and that vaccination increases when the shots come to where people already are.
Earlier this month, the federal Department of Health and Human Services expanded its Health Center COVID-19 Vaccine Program in a bid to reach underserved populations in primary care settings. Almost 1,500 health centers across the country are now eligible to join the program, which launched in February in just 250 sites. About 70 percent of the people who have been vaccinated through the program are racial or ethnic minorities, HHS said.
Neetu Abad, a behavioral scientist at the CDC, draws a parallel between vaccination and voting.
“What increases uptake is making it easier,” she said, emphasizing the need for mobile and pop-up vaccination clinics as well as primary-care sites.
Shantanu Nundy, a primary care physician who works part time at Neighborhood Health, which serves more than 40,000 predominantly low-income and uninsured patients in Northern Virginia clinics, said neither he nor his full-time colleagues have seen patients refuse to get vaccinated once they have taken time to talk about it.
“Most of these communities really do respect doctors,” said Nundy. “They stand up when I walk in the door.”
The Johnson & Johnson vaccine requires a single dose, making it an attractive option when trying to inoculate hard-to-reach groups. (Matt Rourke/AP)
The key has been listening and responding to their concerns — and when necessary, sharing personal stories, including on one occasion showing a patient a photograph of his own mother, whom Nundy had gotten vaccinated.
The problem, Nundy said, is that he doesn’t have Johnson & Johnson or an equivalent shelf-stable vaccine at hand and instead has to refer patients to another vaccine-only site. That means they have to make a new appointment, will have to take more time away from work and may decide not to follow through, particularly as many of his patients are undocumented.
“I can give them the flu shot, the shingles shot, do bloodwork, but I can’t give them the covid shot,” said Nundy. “I am able to win almost all of them over, so let’s give them the shot there and then.”
ChesPenn Health Services, a federally qualified health center based in Chester, Pa., operates three vaccination clinics a week while trying to maintain a regular schedule of care..
The two-shot Moderna vaccine has involved a herculean task of calling patients to schedule special appointments, rather than being able to offer the shots when patients show up for routine care, said ChesPenn CEO Gary Davis.
A little more than a mile away, the Medicaid managed care company AmeriHealth Caritas has transformed its wellness center into a vaccination site. With regular programs — from nutrition to exercise and job preparedness — on hold because of the pandemic, the insurance company was able to collaborate with the county and reconfigure the space as a mini mass-vaccination center.
“We bring it to them,” said CEO Paul A. Tufano, describing efforts to call every member, schedule appointments and provide education around the coronavirus and the vaccine, as well as offering to help with transportation for the shot.
The program is now delivering about 240 shots a day.
But by using Moderna, appointments have to be scheduled rather than allowing walk-ins at the site, which sits close to a busy Family Dollar store.
Even if the Johnson & Johnson vaccine pause is lifted Friday, which health authorities are leaning toward, clinicians like Bates wonder if there will be an ongoing setback.
“What’s yet to be determined is are people going to say ‘No, I don’t want that one,’ ” he said.
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