Virginia has invested more than $20 million in vaccine outreach. But demand is still dropping.

On a warm day in May, Garry Wakely strode vigorously down the streets of downtown Bristol, Virginia, stopping just short of flat-out run.  In less than 15 minutes, a group of volunteers and employees with the Mount Rogers Health District would pack up the day’s COVID-19 vaccination clinic at the local public library.

But nurses had punctured a new vial for a handful of latecomers, leaving three doses left over.

Wakely, the library’s program and marketing coordinator, wanted to use up those shots. A bespectacled man with close-cropped hair and a salt-and-pepper goatee, he lives on the Virginia side of the city and was quick — along with his friends and family — to get vaccinated. “All of us were like, ‘As fast as possible, please,’” Wakely said. 

Disappointingly, to him, not everyone in the city feels the same way. On a map charting Virginia’s local vaccination rates, Bristol is visible as a fleck of pale blue, with just over 31 percent of its population fully immunized. In some nearby counties, including Scott and Lee, the rates are even lower.

Dr. Karen Shelton, director of the Mount Rogers and Lenowisco Health Districts, said data from the Virginia Department of Health might not reflect the full reality on the ground. Many counties in Southwest Virginia are closer to the borders of Tennessee or North Carolina than they are to other parts of the state. With fuzzy boundaries and many patients willing to travel for a shot — particularly in the early weeks of the vaccine rollout — Shelton said the system doesn’t always capture every patient who received a dose outside Virginia.

“I know for a fact that people who are vaccinated in North Carolina, their vaccine numbers are not reflected in our state numbers,” she said. Still, national data suggests that vaccination rates in neighboring out-of-state counties are lower than they are in Virginia. And on the ground, it’s difficult to deny that demand for vaccines has sharply plummeted.

Wakely approached two construction workers tearing up a strip of asphalt near State Street, the city’s main drag. “Have you been vaccinated?” he asked. No, they replied. “Do you want one?” The men shook their heads. He burst into State Line Bar & Grille, where two servers were prepping for dinner service over the pulsing refrain of Katy Perry’s “Roar.”

“I think everyone who wants it has already gotten it,” one woman told him. “I’m starting to get the same feeling,” Wakely responded. After a couple more stops, he returned to the library. A few minutes later, volunteers trickled out the side doors, unopened vials packed into plastic coolers. 

The remaining three doses went unused.

A peak and a drop

For months, health officials have been anticipating a sharp drop in appetite for the same vaccines that some patients once drove hours to receive. But the dramatic dip — particularly in certain areas of the state — still came more quickly than expected.

In Virginia, demand peaked in early April when the state administered almost 110,000 doses in a single day. Since then, it’s been on a steady downward trend, with the exception of one five-day jump in mid-May. State vaccine coordinator Dr. Danny Avula credited a “Statewide Day of Action” that promoted grassroots vaccine advocacy, but it also corresponded with the national announcement that 12 to 15-year-olds had become eligible for the Pfizer vaccine. As of June 1, Virginia was administering an average of 27,087 doses a day.

So far, Gov. Ralph Northam has stayed away from the kind of widespread incentives making headlines in other states, including neighboring West Virginia — where Gov. Jim Justice offered $100 savings bonds in exchange for shots — and Ohio, which notoriously entered vaccinated residents into one of five $1 million lotteries. But the state has invested roughly $22.7 million dollars into outreach efforts meant to connect more Virginians with vaccines — or convince them that it’s worth their time to get a shot.

Among those efforts include mobile vaccine vans, marketing materials and nearly $16 million for two contracts with Elite Business Strategies, a company that’s deployed 366 contractors across the state to “conduct hyper-local vaccine education and outreach,” according to Virginia Department of Health spokeswoman Melissa Gordon. In many cases, those contractors are joining National Guard members and existing staff in addition to new community health workers hired through a nearly $8 million infusion of federal funding to local health departments.

The results are sometimes mixed. Just a couple hours after volunteers packed up the vaccine clinic in downtown Bristol, two nurses and an administrator with the Mount Rogers Health District descended on Northwood Middle School, a low-slung red brick building at the bottom of a bumpy mountain road in Saltville. The surrounding hills are dotted with family farms, and the area is remote enough that cell service doesn’t reach there.

The school was closed, but the department was there for a mobile vaccine clinic — one of a handful of events it had begun staging over the last few weeks. With a nearly empty parking lot, the National Guardsman there to help direct traffic was constrained to chatting with Rick Webster and Frank Gonzales, two Elite contractors who had just arrived in Southwest Virginia earlier that week from Idaho and California, respectively.

“I put that sign out there,” Gonzales said, pointing to a small blue banner advertising “COVID Vaccine Available Here.” Otherwise, he said, they were largely awaiting direction from the local health department.

“If traffic came in, we’d direct traffic,” he said. “If there were enough people to be in line, we’d make sure they kept up social distancing.” Earlier that week, they had assisted with another mobile clinic in the parking lot of a Hobby Lobby in Galax. Eight people had gotten their shots there. But even after nurse Brittani Counts put out a call on the local country radio station, no one stopped along the road running past Northwood Middle. At the end of three hours, the department packed up the clinic without giving out a single vaccine.

“I think we’re going too far out,” murmured Robynne Silva, an office services specialist for the department. Some of the most successful mobile clinics have been at Dollar Generals or local grocery chains — settings where there’s already a built-in audience of shoppers. But the health districts overseen by Shelton span 13 counties and three cities in some of the most rural areas of the state. 

‘You can still squeeze a lot of cases out of some districts’

In Southwest Virginia, like many other localities, it’s still not clear how many people are resistant to the vaccine and how many just haven’t had access to it.

“That’s the really tough question,” said Bryan Lewis, a computational epidemiologist at the University of Virginia’s Biocomplexity Institute. For the last year, he’s worked on modeling to predict the spread of COVID-19 across the state. In recent weeks, those models have included state-level data on vaccine acceptance, a measure of how many Virginians have already been vaccinated or would be willing to accept a shot if one were offered to them.

The data in UVA’s modeling comes from Census Bureau polling and daily Facebook surveying by the Delphi Group at Carnegie Mellon University, which can be broken down at the state and local level. Virginia, in many regards, is doing better than the national average when it comes to embracing the vaccine — and far better than some of its southern neighbors. 

That’s reflected in the progress the state has made toward President Joe Biden’s stated goal of distributing at least one dose to 70 percent of adults by July 4. As of Friday, Virginia had reached 67.4 percent, according to VDH data. A recent New York Times analysis found the state, as a whole, could reach the national goal in 13 days if vaccinations continued along their current trajectory. In Tennessee, it’s estimated to take six months.

But celebrating state-level accomplishments risks underplaying the wide disparity in vaccination rates between different regions, Lewis said. Northern Virginia, specifically, accounts for a large percentage of the state’s vaccinated adults — enough that by early May, UVA researchers were estimating that the region could avoid another surge in cases.

Many counties in Southwest and Eastern Virginia, by contrast, have less than 40 percent of their total populations vaccinated with even one dose. Estimated acceptance rates in the regions hover below 60 percent. That leaves them more vulnerable to the kinds of trends seen last year, when cases of the virus ticked upward in late summer and contributed to massive spikes in disease throughout the fall and winter. The risk is greater as more transmissible variants circulate across the state.

“Saying that 70 percent of Virginians are vaccinated when most of them are in Northern Virginia just isn’t accurate,” Lewis said. “Because if you dial up transmission rates, you can still squeeze a lot of cases out of some districts.”

It all comes down to the concept of herd immunity — when enough people are immune to a disease to prevent its further spread. Right now, the threshold for COVID-19 is still somewhat nebulous. Many experts have cited immunity among 60 to 70 percent of the population, but Lewis said some epidemiologists have been surprised to see a drastic decrease in new infections, both in Virginia and across the country, even with fewer than 50 percent of people fully vaccinated against the disease.

As vaccination numbers lag, the herd immunity goal is also getting more pushback from scientists worried that it’s actually dissuading some Americans from getting a shot.

“I think a lot of people think it’s unnecessary,” Lewis said. “Like, ‘I already had the virus, so I don’t need it,’ or ‘This thing’s going to die out anyhow, so why should I get a vaccine?’” But multiple studies have shown that natural immunity is much less protective against new infections than immunity conferred by immunization. COVID-19 also differs from diseases such as measles or smallpox in that the vaccines aren’t protective long-term. 

Developers have said it’s likely booster shots will be needed within a year of initial vaccinations. It’s possible that COVID-19 vaccines will become annual, just like they are for the flu. Epidemiologists also suspect warm summer weather plays a role in suppressing new infections — leaving many worried that some communities are vulnerable to fall surges. Already, hospitalizations are rising among unvaccinated teenagers and young adults. On Friday, the director of the U.S. Centers for Disease Control and Prevention Director urged parents to have their children immunized.

“We’ve seen this play out already,” Lewis said. “As this virus has more time to get around, it just learns more tricks. So you want to put the fire out fast. If you put it out slowly, it still has a chance to pop embers and spread some more.”

‘It hasn’t been enough of a priority’

With more than half of all Virginians still yet to be fully vaccinated, the fundamental question comes down to “Why?” National surveying has attempted to classify unvaccinated residents into a few different categories, the most widely accepted of which come from the Kaiser Family Foundation. Its data team defines four groups, from the “as soon as possible” to the “definitely not” camps.

“What we’ve seen over time is an increase in vaccine enthusiasm and a corresponding decrease in the share of people who say they just want to wait and see,” said Liz Hamel, KFF’s director of public opinion and survey research. However, there hasn’t been a real reduction in the percentage of people who are staunchly opposed to the shot. And as the “wait and see” group diminishes, the “no way” group is making up a more substantial share of the unvaccinated.

The idea of vaccine hesitancy, though, is still controversial among many public health experts. Early narratives that Black patients would be more hesitant to take the vaccine ignored issues of access and weren’t borne out by later polling, scholars pointed out. A recent KFF survey also found that Hispanic adults were twice as likely as White adults to say they wanted a vaccine as soon as possible. But they reported more barriers, including worries that side effects would force them to miss work.

“I do think there is a group that wants to be vaccinated and hasn’t figured out how to get the vaccine yet,” Hamel said. “But it’s getting smaller and smaller over time.” National polling suggests that rural residents, Republicans and White Evangelical Christians are far more likely to “definitely” oppose the shots. But Shelton, director of the Mount Rogers, Lenowisco and Cumberland Plateau Health Districts, is equally worried her residents will feel stereotyped by the idea of a rural-urban divide — a sort of self-fulfilling prophecy that will further discourage vaccinations.

“I don’t want to put labels on people and make them feel turned off or standoffish or like, ‘Oh, the government is just saying this about us,’” she said. “You don’t want to turn people away before they’ve had an opportunity.” And for several weeks of Virginia’s rollout, the Southwest far outpaced other areas of the state, quickly moving through eligible populations.

Avula, the state’s vaccine coordinator, has a different theory for the roughly 30 percent of adults who haven’t gotten a first dose yet. “I actually think the larger percentage of people who are not vaccinated right now are people who may have questions one way or another, but it hasn’t been enough of a priority for them,” he said. 

That’s made convenience the operative word of the day in Virginia. Health districts once tasked with enforcing strict priority lists are bringing coolers of vaccines to fairgrounds, breweries and minor league baseball stadiums. Officials are touting their ability to offer all three varieties of the shot. Dr. Noelle Bissell, director of the New River Health District, said her department was able to vaccinate 50 people when it staged a mobile clinic on the shores of Claytor Lake State Park.

“We’re switching our focus from large vaccination clinics to our smaller mobile events,” said Amy Popovich, nurse manager for the Richmond-Henrico Health District, at a recent news conference announcing the department’s new summer vaccination campaign (#HotVaccinatedSummer). That includes a public interest form where businesses, neighborhood organizations and other private groups can request a “Cool Cubes Crew” — nurses and outreach workers bearing backpack coolers full of vaccines. 

Behind the hashtags, though, is a quiet acknowledgement that the final legs of the vaccine rollout are a lot more work. Much of the messaging is now focused on what Virginians won’t have to do once they’re vaccinated — wear a mask, for example, or distance from older, more vulnerable relatives. Breanne Forbes Hubbard, the population health manager for Mount Rogers, said the district is trying to emphasize that vaccinated sports teams won’t have to quarantine after an exposure (many of its new cases have been linked to youth teams and social gatherings, like proms).

But misinformation is still a major barrier. At a recent talk for high schoolers, Forbes Hubbard said some students — inspired by a recent tweet from Elon Musk — asked about microchips in vaccines. Sometimes, new research or technological advances are disseminated and warped as they make their way across social media. That rumor started gaining new traction after news that a medical device company was testing syringe labels — not vaccines — with microchips that would help health workers determine if a vial was expired or counterfeit.

“I have to keep up with those sorts of things because otherwise I don’t have a rebuttal to that,” said Fati Craighead, an outreach support specialist for the Richmond-Henrico Health District. On a hot day in late May, she headed up one of several canvassing teams going door-to-door in south Richmond, in a neighborhood behind George Wythe High School. 

It was the second week of the district’s door-to-door campaign, and outreach workers were there to spread the word about a walk-up clinic at the school later that evening. But neatly stacked on a clipboard, Craighead also carried stacks of surveys recently developed by VDH. They asked canvassers to summarize every interaction, from an unanswered door to outright refusal (or, in many cases, residents who have already been vaccinated). In the case of refusal, though, they asked for a reason, from concerns over vaccine safety to government mistrust or some reason that health workers have never heard before.

“A couple weeks ago, I had someone tell me their blood type protected them from COVID,” Craighead said — a misinterpretation of early studies that other research has called into question. Just a few minutes earlier, one homeowner had refused to open the door for her. But at the latest house, Craighead and a coworker were happily accosted by two friendly pitbulls.

“Get off them,” a woman called out. As it turned out, she and her husband had been waiting for a vaccine, and Craighead was able to register them for an upcoming clinic. It was a different type of accomplishment than the district witnessed in March and April, where they vaccinated thousands at large-scale clinics in a single day.

Still, it was progress.