Ensuring Health Equity for COVID-19 Vaccines: January 8, 2021 Challenges Prepared By: & Considerations Margaret Kirkegaard, MD, MPH

Ensuring Health Equity for COVID-19 Vaccines: January 8, 2021 Challenges Prepared by: & Considerations Margaret Kirkegaard, MD, MPH

Copyright © 2020 Health Management Associates, Inc. All rights reserved. The content of this presentation is PROPRIETARY and CONFIDENTIAL to Health Management Associates, Inc. and only for the information of the intended recipient. Do not use, publish or redistribute without written permission from Health Management Associates, Inc. OUR SPEAKER

Margaret Kirkegaard, MD, MPH, Principal (Chicago) ➢ Margaret is Board Certified in Family Medicine with expertise in integration of public health and healthcare delivery systems and population-based health care delivery for vulnerable and underserved groups. Since March, She has been assisting local health departments with their COVID response.

+ Imperative for COVID-19 Vaccination Strategy + COVID-19 Vaccine Planning and Distribution + Health Equity Context + Developing Effective Vaccination Strategies + Health Home Roles in Development and Execution of COVID-19 Vaccine Strategies

“Immunizing the U.S. population against COVID-19 will likely require the single largest vaccination campaign ever undertaken… As with many COVID-19 activities, a ‘whole of government’ response, with broad participation by health and human services, economic development, education, and public safety agencies, as well as private sector partners and the public, will be critical to its success.”

Letter from the National Governor’s Association

Pfizer Moderna

Technology mRNA mRNA used

Approx. 95% efficacy in Phase 3 Approx. 95% efficacy in Phase 3 Efficacy trials to date trials to date

EUA Pfizer received EUA Dec 12. Moderna received EUA Dec 18.

• Store at -70 degrees C • Store at -20 degrees C • 2 doses, 21 days apart • 2 doses, 28 days apart Challenges • Must be used within 5 days • Frozen for 6 mons; frig for 30 of breaking cold chain days

As of December 20, 2020…

Phase 1a: 1) healthcare personnel and 2) residents of long-term care facilities.

Healthcare personnel - paid and unpaid people serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials.

Long-term care facility residents - adults residing in facilities that provide services, including medical and personal care, to persons unable to live independently.

Phase 1b: Adults over age 75 and essential workers such as first responders, teachers and other education workers including day care workers, food and agriculture workers, correctional facility staff, postal workers, public transit workers, and people who work in manufacturing and in grocery stores.

Phase 1c: Adults ages 65 to 74 years, people 16 to 64 years old with high-risk medical conditions (obesity, smoking, heart disease, lung disease), and essential workers not included in the second phase of vaccination.

Health homes beneficiaries likely to fall into phases 1b and 1c.

❑CDC is partnering with CVS, Walgreens, and Managed Health Care Associates, Inc. to offer on-site COVID-19 vaccination services for residents of nursing homes and assisted living facilities. ❑The Pharmacy Partnership for Long-term Care (LTC) Program provides end-to- end management of the COVID-19 vaccination process, including cold chain management, on- site vaccinations, and fulfillment of reporting requirements. ❑Nearly 100% of LTCF have enrolled and vaccination has started

Dr. Michael Osterholm CIDRAP, University of Minnesota, JAMA Aug 25, 2020

❑ COVID has exacerbated long- standing health disparities ❑ Effective vaccine strategies will require addressing both logistical and attitudinal barriers ❑ Our experience with H1N1 (most recent pandemic) and annual experience with influenza vaccination does not provide confidence

https://www.kff.org/report-section/covid-19-racial-disparities-in-testing-infection-hospitalization-and-death-analysis-of-epic-patient-data-issue-brief/ Copyright © 2020 Health Management Associates, Inc. 11 All rights reserved. PROPRIETARY and CONFIDENTIAL COVID-19 ATTITUDES

Political polarization: • 85% of Democrats say that COVID-19 is a major threat • 46% of Republicans say that COVID-19 is a major threat

• 62% of adults in the US worry that "political pressure from the Trump administration will lead the FDA to rush to approve a coronavirus vaccine without making sure that it is safe and effective.”

"Plandemic": "Truth that coronavirus was planned by powerful people." • Definitely true: 8% • Definitely NOT true: 23% • Probably true: 28% • Not sure: 13% • Probably NOT true: 28%

Difficult to determine truth: “When they get news and information about the coronavirus outbreak, they generally find it …” • Difficult to determine what is true and what is not: 53% • Easy to determine what is true and what is not: 45% • Refused to answer: 2%

Pew Research Center, July 2020 Kaiser Family Foundation

Copyright © 2020 Health Management Associates, Inc. 12 All rights reserved. PROPRIETARY and CONFIDENTIAL ESTIMATING INFLUENZA A (H1N1) 2009: VACCINATION COVERAGE AMONG CHILDREN AND ADULTS (Oct 2009–May 2010)

Group Vaccination Rate Persons aged ≥6 mos 27.0

Children, 6 mos to 17 yrs 40.2 Persons ≥18 yrs 22.7 Persons in initial target groups** 34.2

Persons 25–64 yrs, at high risk†† 28.6

Persons 25–64 yrs, not in initial target groups 16.7

Persons aged ≥65 yrs 28.8

** Pregnant women, persons who live with or provide care for infants aged <6 months, health–care and emergency medical services personnel, children and young adults aged 6 months—24 years, and persons aged 25—64 years who have medical conditions that put them at higher risk for influenza– related complication †† High risk includes asthma, other lung problems, diabetes, heart disease, kidney problems, anemia, weakened immune system caused by a chronic illness or by medicines taken for a chronic illness. CDC Flu Vax Coverage

Race/Ethnicity Vaccination Rate

Overall 45.3

White only, non-Hispanic 48.7

Black only, non-Hispanic 39.4

Hispanic 37.1

Other, non-Hispanic Overall 41.2

Asian 44.0

American Indian/Alaska Native (AI/AN) 37.6

Other or multiple races 39.7

CDC Flu Vax Coverage

https://news.gallup.com/poll/327425/willingness-covid-vaccine-ticks.aspx

https://news.gallup.com/poll/325208/americans-willing-covid-vaccine.aspx

Literature demonstrates effective strategies for reducing barriers and increasing vaccine rates: ✓ Increased vaccine access through convenient sites and times ✓ Provider education, feedback on rates compared to others ✓ Providing registries, gap lists; employing recall/reminder systems (personalized better than generalized) ✓ Removing co-pays ✓ Embedded processes, e.g., flu shot before hospital discharge Literature related to addressing vaccine hesitancy more nuanced: ➢ Parental vaccine hesitancy addressed through affirmation of parent’s wishes for well-being of children, addressing vaccine safety, and reducing pain with injections ➢ Vaccine hesitancy in AA communities is impacted by engaging elders, affirming herbal/alternative therapies, and addressing overarching distrust of government systems Unknown how well lessons learned from adult or pediatric vaccine hesitancy will translate to COVID-19 vaccine.

➢ Influenza vaccine rates are as low as 25% ➢ In people with SMI, vaccination can be increased by: peer support, influence, and belief in the effectiveness of the vaccine. ➢ Education by a health care professional about the role and importance of vaccination increased uptake by 4-fold. ➢ Running vaccination clinics parallel to mental health services can increase vaccination rates by up to 25%.

Published Online: December 15, 2020. doi:10.1001/jamapsychiatry.2020.4396 Copyright © 2020 Health Management Associates, Inc. 19 All rights reserved. PROPRIETARY and CONFIDENTIAL CHALLENGES AND LESSONS LEARNED FROM FIRST FEW WEEKS

➢ Misestimation of doses in Pfizer vials (really 6 or 7 doses, not 5; impact on second dose distribution?) ➢ Paradoxical vaccine hesitancy AND vaccine demand must be managed (unscheduled individuals showing up and demanding vaccine) ➢ Health system “territories” not aligned with LHD jurisdictions ➢ Multiple IT systems: scheduling, registration, HR systems, EHRs do not necessarily communicate ➢ How to combat falsehoods without giving more airtime to them (e.g. “vaccine causes infertility”) ➢ Logistics (parking, pens, security) critically as important as clinical elements Copyright © 2020 Health Management Associates, Inc. 20 All rights reserved. PROPRIETARY and CONFIDENTIAL Potential Roles for Health Homes ROLES FOR HEALTH HOMES

+ Identify/map hard-to-reach populations; assess population + Develop collaborations with vaccination providers + Assess and develop marketing and community education pathways, build on current messaging related to testing, mask-wearing, and social distancing; assess communication routes for vaccine access and second dosage + Build public confidence now; engage community leaders and spokespersons + Review state and local plans and ability + Organize like-minded or regional CBOs to participate in vaccine administration + Helpful to have a back-bone + Previous experience, potential organization to provide structure and collaborators, vaccinators, ability to interface with public health report

• Executive Summary for NYC Vaccine Distribution Plan https://www.cdc.gov/vaccines/covid- 19/downloads/new-york-city- jurisdiction-executive-summary.pdf

• Draft New York State COVID-19 Vaccination Administration Program Available: https://covid19vaccine.health.ny.gov/

➢ Identify whether key provider partners such as PCPs/FQHCs will be providing vaccinations ➢ If not current provider partners, then identify probably vaccine access points such as HD or pharmacies ➢ Confer with provider partners or other PODs about collaborative opportunities ➢ Provide support and logistical arrangements for LEP, homeless and other vulnerable populations ➢ Work with health plans to establish benefits such as transportation ➢ Develop shared patient communication/education strategies ➢ Ensure that COVID-19 vaccination is a component of every care plan

Mapping to help Target Communities ❑ CDC Social Vulnerability Index points to “hot spots” ❑ Identify and leverage key providers and partners in these communities ❑ Where are CBO sites and clients located?

Use multiple forms of Partner with Health media to communicate Department or Providers to key messages about plan and conduct vaccine the vaccine, e.g., no PODs in community cost, effective, where locations. they can get it.

At PODs in community, Conduct outreach, assist with security, assist with ensuring safe distancing, transportation to provide SDOH supports ensure PODs are well (e.g., food distribution). utilized.

Literature related to vaccine hesitancy points to overarching distrust of government systems, particularly in AA communities.

“Familiarity and trust with the messenger seems to be a key feature" in effective vaccine education and social marketing campaigns.

Culturally sensitive, linguistically appropriate messages tailored to sub-populations that come from trusted community members, e.g., CBOs, faith-based groups, neighborhood pharmacists tend to be effective.

Example: Cook County (Chicago) engaged two young community leaders (“influencers”) to film health education videos for COVID-19 infection control

+ Tanya Lozano, founder of Healthy Hood Chicago, and McKinley Nelson, founder of Project Swish

A network of Ohio CBOs mobilized to prevent COVID and meet social needs of 2,000 socially isolated elderly in low-income housing developments. They provided - • Health Monitoring and Care Coordination – Telephonic/virtual health assessments, service coordination, case management, providing COVID Amazon Echo App • Food and Supply Delivery • Community and Volunteer Mobilization • Transportation Services • Communications – Communication plans, hotlines, providing the latest Covid-19 facts and sending daily updates • Infection Control – Sanitation of common spaces; Making PPE and ensuring residents and staff have masks and sanitizers • Social Connections - Providing iPads for FaceTime meetings with family and friends Results show that high risk, socially isolated seniors trust affordable housing development service coordinators as health and safety messengers and navigators. CBOs are a critical partner in ensuring equitable vaccination.

MARGARET KIRKEGAARD Principal, Chicago Mobile: 630-272-4993 [email protected]