The tremendous job of vaccinating the nation is ongoing, but the further they are from urban centers the harder it is for rural Americans to get a COVID-19 vaccine.
It is also not easy to tell rural residents when to be vaccinated, and the extraordinary amount of misinformation that downplayed the risk of the coronavirus over the past year has affected rural residents' willingness to receive the vaccine.
Working in rural health care, we have studied the barriers to health care for these patients to find ways to ensure health and safety.
The problem with large batches and cold storage
The first two vaccines approved – one from Pfizer
and BioNTech and the other from Moderna
– are mRNA vaccines. It's a new type of vaccine that uses the molecular instructions to build viral proteins instead of injecting parts of the weakened virus itself. Both must be kept in very cold temperatures.
To ensure stability, the vaccine doses are shipped in special containers with dry ice. Currently, vaccines are only supplied in large quantities. The Pfizer vaccine comes in increments of 975 doses, which is a challenge for small hospitals.
Urban areas will be able to distribute these doses quickly, but finding enough patients to vaccinate quickly in rural areas can be more difficult.
Moderna's vaccine is a little easier to use with a minimum order of 100 doses.
Both vaccines also require two doses per person, with the second dose of the Pfizer vaccine being given 21 days later and that of Moderna 28 days later.
As a result, vaccine distribution efforts will favor hubs targeting more populous areas to avoid wasting vaccines or unable patients to receive their second dose.
Cold storage is another challenge as small hospitals are less likely to have expensive freezers. The Pfizer vaccine must be stored at minus 70 degrees Celsius and the Moderna vaccine at minus 4 degrees Celsius. There are limits to how often the vaccine shipping containers can be opened and how quickly the vaccines must be distributed. After thawing and priming, the Pfizer vaccine must be used within five days and that of Moderna within 30 days.
Each patient must receive both vaccine doses from the same manufacturer to ensure safety and effectiveness, which adds to the challenge. Manufacturers have included personal dosage cards that patients can carry with them to help meet this challenge.
Rural America adopts COVID-19 and vaccines
Rural America already has difficult barriers to accessing health care.
There are fewer healthcare providers serving a more geographically diverse population than in major cities. In many of these areas, rural hospitals have closed at an alarming rate, and people have to continue traveling for care. The population is also older. Public transportation that could help poor or elderly residents get to hospitals is rare, and distance and geography, such as: Mountain roads, for example, can make driving to these locations take some time.
It has also proven difficult to get accurate information about the vaccine and obtain it in rural areas. Many rural counties still have limited access to broadband internet connections, smartphone services and other technologies. This often means that residents rely on television, newspapers, and radio for news, which can limit the depth and scope of information.
While some rural counties have started getting the word out, many seem to have no concrete plans on how to let their residents know how and when each person can get the vaccine, let alone concrete plans to actually give it. They often only rely on local press releases that many residents never see.
Rural health nonprofits have tried to fill this gap and improve rural communication about vaccines and the pandemic. For example, the Care Compass Network, which coordinates organizations in southern New York, has hosted webinars with the latest information on the virus and vaccines. But there is still a lot to be done.
Rural Americans' views of vaccines are influenced by the media and word of mouth, politics and religion, and previous experiences with vaccination and, perhaps most importantly, the difficulty of accessing health care.
In a survey by the Kaiser Family Foundation in December, about 35% of rural Americans said they likely or definitely would not get the vaccine, more than the 27% nationwide.
Small series, new vaccines and pharmacies
To get enough vaccinations in the US to end the pandemic, more work is needed in all of these areas. This includes improving shipping and warehousing processes so orders can be split and distributed to smaller hospitals, more vaccine doses can be distributed, and communications can be improved.
With Moderna's vaccine arriving in smaller quantities and not requiring such low temperatures for stability, it may prove to be more accessible to rural areas in the near future. Utah has already used these properties to provide initial doses to smaller hospitals outside of its urban areas and has begun vaccinating health care providers. Pfizer has announced that it may offer smaller batches through April.
Other vaccines on the horizon are also expected to have less stringent storage requirements and may be given in a one-shot method rather than a two-dose series. However, the declining number of rural hospitals remains a challenge to provide vaccines to patients. Approving the vaccine through community pharmacies – especially if independent pharmacies are involved – could ultimately help expand the distribution network in rural areas.
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Bennett Doughty is a clinical assistant professor in pharmacy practice at Binghamton University, State University of New York. Pamela Stewart Fahs is Professor of Rural Nursing at Binghamton University, State University of New York. This was first published by The Conversation – "Why It Is Harder Getting COVID-19 Vaccines To Rural Americans Than It Looks And How To Break The Barriers".