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  • The COVID Emergency Is Ending. Is Vaccine Outreach Over Too?

    The COVID Emergency Is Ending. Is Vaccine Outreach Over Too?

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    Stephen B. Thomas, the director of the Center for Health Equity at the University of Maryland, considers himself an eternal optimist. When he reflects on the devastating pandemic that has been raging for the past three years, he chooses to focus less on what the world has lost and more on what it has gained: potent antiviral drugs, powerful vaccines, and, most important, unprecedented collaborations among clinicians, academics, and community leaders that helped get those lifesaving resources to many of the people who needed them most. But when Thomas, whose efforts during the pandemic helped transform more than 1,000 Black barbershops and salons into COVID-vaccine clinics, looks ahead to the next few months, he worries that momentum will start to fizzle out—or, even worse, that it will go into reverse.

    This week, the Biden administration announced that it would allow the public-health-emergency declaration over COVID-19 to expire in May—a transition that’s expected to put shots, treatments, tests, and other types of care more out of reach of millions of Americans, especially those who are uninsured. The move has been a long time coming, but for community leaders such as Thomas, whose vaccine-outreach project, Shots at the Shop, has depended on emergency funds and White House support, the transition could mean the imperilment of a local infrastructure that he and his colleagues have been building for years. It shouldn’t have been inevitable, he told me, that community vaccination efforts would end up on the chopping block. “A silver lining of the pandemic was the realization that hyperlocal strategies work,” he said. “Now we’re seeing the erosion of that.”

    I called Thomas this week to discuss how the emergency declaration allowed his team to mobilize resources for outreach efforts—and what may happen in the coming months as the nation attempts to pivot back to normalcy.

    Our conversation has been edited for clarity and length.

    Katherine J. Wu: Tell me about the genesis of Shots at the Shop.

    Stephen B. Thomas: We started our work with barbershops and beauty salons in 2014. It’s called HAIR: Health Advocates In-Reach and Research. Our focus was on colorectal-cancer screening. We brought medical professionals—gastroenterologists and others—into the shop, recognizing that Black people in particular were dying from colon cancer at rates that were just unacceptable but were potentially preventable with early diagnosis and appropriate screening.

    Now, if I can talk to you about colonoscopy, I could probably talk to you about anything. In 2019, we held a national health conference for barbers and stylists. They all came from around the country to talk about different areas of health and chronic disease: prostate cancer, breast cancer, others. We brought them all together to talk about how we can address health disparities and get more agency and visibility to this new frontline workforce.

    When the pandemic hit, all the plans that came out of the national conference were on hold. But we continued our efforts in the barbershops. We started a Zoom town hall. And we started seeing misinformation and disinformation about the pandemic being disseminated in our shops, and there were no countermeasures.

    We got picked up on the national media, and then we got the endorsement of the White House. And that’s when we launched Shots at the Shop. We had 1,000 shops signed up in I’d say less than 90 days.

    Wu: Why do you think Shots at the Shop was so successful? What was the network doing differently from other vaccine-outreach efforts that spoke directly to Black and brown communities?

    Thomas: If you came to any of our clinics, it didn’t feel like you were coming into a clinic or a hospital. It felt like you were coming to a family reunion. We had a DJ spinning music. We had catered food. We had a festive environment. Some people showed up hesitant, and some of them left hesitant but fascinated. We didn’t have to change their worldview. But we treated them with dignity and respect. We weren’t telling them they’re stupid and don’t understand science.

    And the model worked. It worked so well that even the health professionals were extremely pleased, because now all they had to do was show up with the vaccine, and the arms were ready for needles.

    Read: The flu-ification of COVID policy is almost complete

    The barbers and stylists saw themselves as doing health-related things anyway. They had always seen themselves as doing more than just cutting hair. No self-respecting Black barber is going to say, “We’ll get you in and out in 10 minutes.” It doesn’t matter how much hair you have: You’re gonna be in there for half a day.

    Wu: How big of a difference do you think your network’s outreach efforts made in narrowing the racial gaps in COVID vaccination?

    Thomas: Attribution is always difficult, and success has many mothers. So I will say this to you: I have no doubt that we made a huge difference. With a disease like COVID, you can’t afford to have any pocket unprotected, and we were vaccinating people who would otherwise have never been vaccinated. We were dealing with people at the “hell no” wall.

    We were also vaccinating people who were homeless. They were treated with dignity and respect. At some of our shops, we did a coat drive and a shoe drive. And we had dentists providing us with oral-health supplies: toothbrush, floss, paste, and other things. It made a huge difference. When you meet people where they are, you’ve got to meet all their needs.

    Wu: How big of a difference did the emergency declaration, and the freeing-up of resources, tools, and funds, make for your team’s outreach efforts?

    Thomas: Even with all the work I’ve been doing in the barber shop since 2014, the pandemic got us our first grant from the state. Money flowed. We had resources to go beyond the typical mechanisms. I was able to secure thousands of KN95 masks and distribute them to shops. Same thing with rapid tests. We even sent them Corsi-Rosenthal boxes, a DIY filtration system to clean up indoor air.

    Without the emergency declaration, we would still be in the desert screaming for help. The emergency declaration made it possible to get resources through nontraditional channels, and we were doing things that the other systems—the hospital system, the local health department—couldn’t do. We extended their reach to populations that have historically been underserved and distrustful.

    Wu: The public-health-emergency declaration hasn’t yet expired. What signs of trouble are you seeing right now?

    Thomas: The bridge between the barbershops and the clinical side has been shut down in almost all places, including here in Maryland. I go to the shop and they say to me, “Dr. T, when are we going to have the boosters here?” Then I call my clinical partners, who deliver the shots. Some won’t even answer my phone calls. And when they do, they say, “Oh, we don’t do pop-ups anymore. We don’t do community-outreach clinics anymore, because the grant money’s gone. The staff we hired during the pandemic, they use the pandemic funding—they’re gone.” But people are here; they want the booster. And my clinical partners say, “Send them down to a pharmacy.” Nobody wants to go to a pharmacy.

    Read: The COVID strategy America hasn’t really tried

    You can’t see me, so you can’t see the smoke still coming out of my ears. But it hurts. We got them to trust. If you abandon the community now, it will simply reinforce the idea that they don’t matter.

    Wu: What is the response to this from the communities you’re talking to?

    Thomas: It’s “I told you so, they didn’t care about us. I told you, they would leave us with all these other underlying conditions.” You know, it shouldn’t take a pandemic to build trust. But if we lose it now, it will be very, very difficult to build back.

    We built a bridge. It worked. Why would you dismantle it? Because that’s exactly what’s happening right now. The very infrastructure we created to close the racial gaps in vaccine acceptance is being dismantled. It’s totally unacceptable.

    Wu: The emergency declaration was always going to end at some point. Did it have to play out like this?

    Thomas: I don’t think so. If you talk to the hospital administrators, they’ll tell you the emergency declaration and the money allowed them to add outreach. And when the money went away, they went back to business as usual. Even though the outreach proved you could actually do a better job. And the misinformation and the disinformation campaign hasn’t stopped. Why would you go back to what doesn’t work?

    Wu: What is your team planning for the short and long term, with limited resources?

    Thomas: As long as Shots at the Shop can connect clinical partners to access vaccines, we will definitely keep that going.

    Nobody wants to go back to normal. So many of our barbers and stylists feel like they’re on their own. I’m doing my best to supply them with KN95 masks and rapid tests. We have kept the conversation going on our every-other-week Zoom town hall. We just launched a podcast. We put out some of our stories in the form of a graphic novel, The Barbershop Storybook. And we’re trying to launch a national association for barbers and stylists, called Barbers and Stylists United for Health.

    The pandemic resulted in a mobilization of innovation, a recognition of the intelligence at the community level, the recognition that you need to culturally tailor your strategy. We need to keep those relationships intact. Because this is not the last time we’re going to see a pandemic even in our lifetime. I’m doing my best to knock on doors to continue to put our proposals out there. Hopefully, people will realize that reaching Black and Hispanic communities is worth sustaining.

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    Katherine J. Wu

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  • Annual COVID Shots Mean We Can Stop Counting

    Annual COVID Shots Mean We Can Stop Counting

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    A couple of weeks ago, a friend asked me how many COVID shots I’d gotten so far. And for a brief, wonderful moment, I forgot.

    “Three,” I told them, before shaking my head. “No, actually, four.” I had no trouble recalling when I’d received my most recent shot (September). But it took me a moment to tabulate all the doses that had preceded it.

    By this point in the pandemic, a lot of people must be losing track. “I actually think this is a good thing,” says Grace Lee, a pediatrician at Stanford, and the chair of the CDC’s Advisory Committee on Immunization Practices. Now that so many Americans have racked up several shots or infections, she told me, the question is no longer “‘How many doses have you gotten cumulatively?’ It’s ‘Are you up to date for the season?’”

    The flip is subtle, but it marks a rethink of the COVID-vaccination paradigm. We’re at a define-the-relationship moment with these shots, when people are trying to commit—to normalize them as a routine part of our lives. At a September ACIP meeting, CDC officials noted that “we are changing the way we are thinking about these vaccines,” and trying to “get on a more regular schedule.” If COVID shots are here for good, then at least we can be rid of the bother of counting them.

    Read: It’s a bad time to be a booster slacker

    Counting doses was more apt early in the vaccine rollout, when it seemed that two jabs (or even one) would be enough to get Americans “fully vaccinated” and out of the danger zone. When more shots followed, they were often advertised with confusing finality: What some initially described as the booster was later retconned as the first booster after a second one was recommended for certain groups. But with immunity against infection more fragile than some hoped, and a virus that quickly shapeshifts out of antibodies’ grasp, those ordinal adjectives have stopped making sense. Until our vaccine tech becomes much more durable or variant-proof, repeat doses will be, for most of us, a fixture of the future—and it won’t do anyone much good to say, “‘I’m on shot 15’ or ‘I’m on shot 16,’” Angela Shen, a vaccine expert at Children’s Hospital of Philadelphia, told me.

    The numbers certainly matter when they’re small: It will continue to be important for people to count off their first few shots, for instance, especially those without a history of infections. But after that initial set of viral-spike-protein exposures, the total count is moot. In most cases, about three vaccinations or infections—preferably vaccinations, which are both safer and easier to accurately track—should be “enough to fully charge up the immune system’s battery” for the first time, says Rishi Goel, an immunologist at the University of Pennsylvania. Further COVID shots will help only insofar as they can recharge the battery toward max capacity when it starts to lose its juice. Scheduling a vaccine, then, becomes a matter of “how long it’s been since your last immunity-conferring event,” regardless of how many exposures a body has racked up, says Avnika Amin, a vaccine epidemiologist at Emory University.

    People who are immunocompromised may need four or more shots to establish that initial immunity charge, and their own (maybe smaller) peak capacity. But ultimately, the threshold effect they experience—a point of “diminishing returns”—is similar, says Marion Pepper, an immunologist at the University of Washington. Given how many vaccinations and infections the U.S. has now logged, the majority of Americans “can be done with counting,” she told me.

    If we’re going to shift our focus to timing shots, instead of counting them, we’ll have to schedule our shots smartly. Several prominent figures have already come out and said that yearly doses are a top choice. Albert Bourla, Pfizer’s CEO, has been pushing that idea since early 2021; Peter Marks, who heads the FDA’s Center for Biologics Evaluation and Research, has been delivering a similar line for several months. Even President Joe Biden has endorsed the annual approach, noting in a September statement that the debut of the bivalent shot heralded a new phase in COVID vaccination, in which Americans would receive a dose “once a year, each fall.”

    That plan is not unreasonable. Shots will have to come with at least some regularity, as variants keep rolling in and immunity against infection ebbs. But re-dose prematurely with a shot with similar ingredients, and the body—still hopped up from the previous dose—may destroy the vaccine before it has much effect, making it about as useful as charging a battery that’s already at 95 percent. SARS-CoV-2 antibody levels drop off steeply in the first six months following a vaccine dose, and then, the rate of drain slows down. It’s as if the immune system goes into “power-saver mode,” Goel told me, which means there might not be a huge difference between revaccinating twice a year or only once. Plus, living out much of the year with lower antibody levels is not as worrisome as it might sound. Although antibodies can be a rather useful proxy for our level of protection, especially against infection, they don’t paint the whole defensive picture: T cells and other fighters tend to stick around for far longer, maintaining safeguards against severe disease. (The immunocompromised and older people may still need more frequent COVID-immunity top-offs.)

    Read: Are we really getting COVID boosters every year forever?

    The optimal pace for COVID vaccination will also depend on the speed at which the virus spews out variants. A yearly schedule works for influenza, Shen told me, but “we know flu’s cadence.” SARS-CoV-2 hasn’t yet settled down into a predictable, seasonal pattern; its waves aren’t relegated to the chilliest months. The degree to which we, as the coronavirus’s hosts, tamp down transmission also matters quite a bit. Having more virus around puts more pressure on vaccines to perform, especially when there aren’t many other mitigation measures in place. If all this talk of “once a year, each fall” turns out to be another red-herring recommendation, Amin told me, it could undermine any messaging that follows.

    All of that said, the autumn regimen may yet stick around because it’s the easiest approach. Flu-shot uptake is far from perfect, but the messaging around it is “simple and clean,” says Rupali Limaye, a behavioral scientist and vaccine-attitudes researcher at Johns Hopkins. After dosing up twice in four weeks as infants, people are asked to get a yearly shot, and that’s it. Compare that with the most convoluted days of COVID vaccination, when people couldn’t dose up without accounting for their age, health status, number of previous doses, vaccine brand, time since last dose, and more. “That’s absolute overload,” Limaye told me. Complicated schedules burn people out—or dissuade them from showing up at all. This fall, when the bivalent shot debuted, a troubling proportion of Americans didn’t even know they were eligible.

    Encouraging COVID vaccines at the same, straightforward pace as flu shots would make it easy for people to sign up for both at once, and maybe, eventually, to get them in the same syringe. Vaccines tend to ride one another’s coattails, Shen told me. “In the fall, there’s a bump in other routine vaccines,” she said, because people “are already there for their flu shot.” It would also make a big difference if the COVID-vaccine recipes changed for everyone at the same time, as they do for flu.

    Read: When’s the perfect time to get a flu shot?

    If we’re going to pivot from numbering doses to timing them, we might as well take the opportunity to discard the term booster as well. Some people don’t understand what it means, Limaye told me, or they default to a logical question—How many more boosters will I need? Plus, booster may no longer fit the science. “When we start updating formulas, it’s not really a booster anymore,” Amin told me. That’s not how we generally talk about flu shots: I certainly couldn’t tell you how many “boosters” of that vaccine I’ve had. (I don’t know, maybe 14? 15?) Pivoting to a terminology of “seasonal shots” could make COVID vaccination that much more routine.

    So, fine, if anyone should ask: I’ve had (count ’em: one, two, three) four doses of the vaccine so far. But more important, I’ve gotten the shot most recently available to me.

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    Katherine J. Wu

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