America’s poor track record vaccinating people against the flu spells trouble for the coming effort to immunize the nation against COVID-19, experts say, particularly in rural areas where the virus is raging out of control.
A USA TODAY analysis of flu vaccine rates among Medicare participants shows that rural counties from West Texas to northern Nebraska to the Upper Peninsula of Michigan had some of the country’s lowest vaccination rates in 2017, the most recent year with data. It’s a pattern that holds true across America. The more rural the county, the lower flu vaccination rates tended to be.
Data for the analysis came from the County Health Rankings project and the Index of Relative Rurality, a metric that ranks counties based on population size, density, remoteness, and built-up area. The analysis identified 604 counties where fewer than a third of Medicare participants received flu vaccines, 580 of which were predominantly rural.
These places were home to more than 13 million people and were spread across the nation; all but nine states had at least one low-vaccination county.
At the extreme, there were 215 counties where fewer than 1 in 4 residents on Medicare were vaccinated.
“We don’t have the convenience of jumping into a Walgreens, CVS or Walmart and getting our flu shot. Our nearest Walgreens and Walmart are 30 miles away,” said Dr. Jennifer Bacani McKenney, a family physician and the Wilson County Health Officer in Fredonia, Kansas, explaining some of the barriers in rural areas that exist in addition to vaccine hesitancy and distrust.
Due to financial, storage and staffing issues, she said, “none of the providers in our county and many private clinics across the state do not provide in-clinic vaccinations, so the patient is required to make an additional appointment to get vaccines at a health department.”
Of course, people who opt out of the flu vaccine might seek it for the coronavirus because the pandemic has killed more people than the annual flu. At the same time, people who previously took the flu vaccine might not get their shots for COVID-19 because the pandemic has intensified Americans’ skepticism of science and drug regulators.
But flu vaccination rates can at least provide clues to how rural America will respond to the arrival of the COVID-19 vaccine. Data on flu vaccination among Medicare enrollees — primary elderly Americans — provide a detailed geographic window into how the COVID-19 vaccine will be accepted by that key at-risk group, said Dr. Randy Hubach, an associate professor of rural health and director of the Sexual Health Research Lab at Oklahoma State University. “I think it’s an accurate contextual representation of what we can probably expect with the COVID vaccine.”
The potential consequences for rural America can be seen in flu data. Historic data from the U.S. Centers for Disease Control and Prevention Wonder database show that the flu virus tends to kill at higher rates in more rural counties.
Experts say if COVID-19 vaccination follows the same pattern as the flu, the flow of people between these communities and the rest of the country will put both city dwellers and rural residents at risk.
Flu vaccination has largely skipped much of rural America because, in part, it’s harder for people in remote communities to get to pharmacies, clinics or hospitals offering vaccines. There’s also a long-standing distrust in the medical system in these areas. Yet getting the COVID vaccine to these areas will be key to tamping down a virus that’s ravaged rural communities, experts said.
“Ensuring vaccine coverage of rural communities is an essential part of the strategy to protect rural communities from COVID-19,” Dr. Thomas Tsai, a surgeon and health policy researcher at Harvard’s T.H. Chan School of Public Health, said in an email.
Researchers don’t know how much of the U.S. population will need to be protected to stop the spread of COVID-19. Estimates range from 50% to as high as 90% of the population to achieve a threshold epidemiologists describe as “herd immunity.”
Reaching that threshold will be a struggle, if the flu vaccine is any indication. Only half the country gets vaccinated for the flu, on average, and surveys show a growing number of people intend to refuse a COVID-19 vaccine. Achieving a much higher vaccination rate with the COVID-19 vaccine will be the difference between a coronavirus that’s endemic and actively circulating and a coronavirus that’s all but wiped out, a goal the nation has attained with the smallpox, mumps and diphtheria viruses.
“How you are going to move that needle from 50% up to 75% really becomes the question,” said Dr. Hubach.
And the prickly problem of vaccine uptake is one that health officials need to figure out quickly. With two COVID vaccine candidates expected to receive emergency use authorization from the U.S. Food and Drug Administration later this month, federal and state health officials are finalizing vaccine distribution plans to immunize the front-line health care workers and nursing home residents that comprise the so-called Phase 1a group, the Americans who will first receive the vaccine against the coronavirus.
That wave of immunizations is expected to occur before the end of the year. Dr. Mancef Slaoui, the chief science advisor to Operation Warp Speed, recently said he expected the first Americans to be vaccinated within two days of the FDA’s authorization. Dr. Nancy Messionier, director of CDC’s National Center for Immunization and Respiratory Diseases, said last week that everyone in phase 1a should expect their first dose within three weeks of a vaccine being authorized.
The rollout thereafter should proceed quickly. On a Dec. 2 Operation Warp Speed call with reporters, Dr. Slaoui said he expected that 20 million people would receive either the Pfizer or Moderna vaccine in December, followed by 30 million people in January and 50 million people in February, pending FDA authorization. In early 2021, vaccinations will proceed beyond front-line health care workers and nursing home residents to essential workers followed by adults with high-risk medical conditions and people aged 65 and older.
But getting vaccines to essential workers and seniors, especially in rural areas, will be an ongoing challenge given the historically low vaccination rates, which researchers sometimes refer to as ‘uptake,’ in rural counties. The reason for low vaccine uptake? A variety of factors including long-standing systemic health and social inequities as well as a distrust of medical providers, says Dr. Hubach.
Dr. McKenney in Kansas is seeing vaccine distrust play out both in private clinic visits and in public town hall discussions about the coronavirus.
“I hear people saying they’re hesitant to take this vaccine,” said McKenney. “They’re nervous. They don’t want to be the first ones. It goes along with the rural mentality of being suspicious of the government and science.”
That worries McKenney because of how hard communities in Kansas and across the Plains have been hit by COVID-19 in recent months.
“The numbers that we’re seeing right now in our communities actually makes me kind of terrified about what’s going to happen before we ever start vaccinating,” she said. “What’s going to happen in the next month or two months?”
Yet despite that damage, people aren’t changing their behaviors. “Even with those high numbers of cases and deaths, it’s still not hitting home for people,” said McKenney. “They’re saying, ‘Only 1 percent die. It’s not a big deal.’”
Rural counties in the Dakotas, Kansas, Montana and Mississippi have seen some of the highest COVID surges with over 300 deaths per 100,000 people. Influenza and other respiratory diseases have also hit many of those same counties hard in the past, though at much lower levels – around 25 deaths per 100,000 on average, according to CDC data from 2018.
Rural residents who opt out of vaccination are far from monolithic in their reasons.
Lynn Ogren said she routinely passes on the flu shot and all other vaccines in Jerauld County, South Dakota, where just over one in five residents was immunized in 2017. The 69-year-old retired rancher and substitute teacher said she instead takes dietary supplements and minds a strict diet to keep in good health. She won’t be getting vaccinated for COVID-19 either, she said.
“I don’t put anything foreign into my body that I don’t need to,” Ogren said. “I’ve never been vaccinated for the flu, and I don’t get vaccinated for anything.”
Jerauld County residents have died of COVID-19 at a rate of more than 640 per 100,000 residents, one of the highest rates in the country.
Health experts warn that if a population doesn’t attain herd immunity, places that haven’t been immunized will continue to see surges in cases and deaths from the virus known by the scientific name SARS-CoV-2. But achieving herd immunity will be a serious challenge in countries like the United States where vaccine hesitancy is widespread. The consequence is a coronavirus that returns seasonally, guaranteeing continued suffering.
“What happens if countries do not reach high vaccine coverage levels? First, SARS-CoV-2 will become endemic but at a low level… with peaks in winter and troughs in summer in the northern hemisphere,” wrote the authors of a letter published last month in The Lancet journal pointing out challenges to herd immunity.
Dr. Roy Anderson, one of the authors and a professor in the School of Public Health at Imperial College London, said in an interview that the virus will continue to circulate if herd immunity isn’t reached. Rural areas will not be spared.
“The virus will remain endemic, but cities will be major reservoirs seeding rural regions,” said Dr. Anderson, who was adamant that the virus would likely not ever go away. “It will be endemic and seasonal.”
Dr. Krutika Kuppalli, an assistant professor in the division of infectious disease at the Medical University of South Carolina, is also concerned.
“Do I think it’s going to become endemic?” said Kuppalli. “Yeah, I do. When we have millions and millions of cases, it seems like it’s going to become endemic. My hope is we get enough people to take up the vaccine.”
Despite rural counties’ historically low rates of vaccine uptake, Hubach sees an opportunity to better communicate with those communities about the COVID-19 vaccine. Tapping faith leaders and community outreach workers that have an understanding of local context and climate is going to be very important. “How do you have them say, ‘Vaccination is one thing we can do for the common good?’,” he said.
In addition to tailoring public health messages to specific communities in rural counties, relying on the patient-doctor bond is an important way to build trust in the COVID-19 vaccine and boost vaccination rates, says Dr. Brian Chow, a physician and principal investigator on AstraZeneca’s COVID vaccine trial at Tufts Medical Center in Boston. Many rural communities have been historically marginalized and denied health care or worse, Chow explained. Promoting COVID vaccination needs to surmount distrust in medical care.
“The majority of people will get vaccinated through their doctor’s office,” said Chow. “Leveraging those relationships will be key. A strong recommendation from their primary care provider really influences whether or not people accept a vaccine.”
Aleszu Bajak is on Twitter at @aleszubajak or can be emailed at email@example.com