Vaccinating Rural America: Q&A with Dr. Amanda Cohn

by Allee Mead

Amanda Cohn, MD, currently serves as the Chief Medical Officer of the National Center for Immunizations and Respiratory Diseases (NCIRD) and Executive Secretary of the Advisory Committee on Immunization Practices. She recently served as Chief Medical Officer on CDC's COVID-19 Vaccine Task Force. Dr. Cohn came to the CDC in 2004 as an Epidemic Intelligence Service Officer and joined the Meningitis and Vaccine Preventable Diseases Branch in 2006, where she focused on prevention and control of meningococcal disease, both domestically and internationally. She then served as Deputy Director of NCIRD's Immunization Services Division. Dr. Cohn is board-certified in pediatrics and is a fellow of the American Academy of Pediatrics. She obtained her medical degree from Emory University School of Medicine and completed a residency in pediatrics at Boston Children's Hospital and Boston Medical Center in Massachusetts.

Cohn discusses the challenges that rural communities face in getting vaccinated against COVID-19 and shares how the CDC is providing funding, creating resources, and partnering with other organizations to increase vaccination rates in underserved communities such as rural, tribal, and communities of color.

How is CDC addressing rural communities as part of the COVID-19 response?

CDC is very concerned about communities with high rates of COVID-19, including rural and tribal communities, as well as people living in congregate settings, such as long-term care facilities or correctional facilities.

CDC has awarded over $3 billion in funding for immunization programs within public health departments in 64 jurisdictions (state, tribal, and territorial). Immunization program managers typically work on routinely recommended vaccinations, but they have now expanded to also take on COVID-19 vaccination. To ensure health equity and expanded access to COVID-19 vaccines:

• 75% of the total funding must focus on specific programs and initiatives intended to increase vaccine access, acceptance, and uptake among racial and ethnic minority communities
• 60% must go to support local health departments, community-based organizations, and community health centers

It is important for us to understand any challenges that rural communities face in addressing the pandemic, including access to healthcare, supplies, and vaccines as well as communicating the science about COVID-19 vaccines.

Over 8,000 CDC staff members have worked on the COVID-19 response and have completed over 3,000 deployments within the United States (to almost every state and territory) and abroad. The CDC Vaccine Task Force currently has over 600 staff members and includes teams and units focused on key populations. One of those units is focused on rural communities. Working with CDC's rural health lead, the unit has conducted listening sessions with rural health clinics, rural family practice physicians, State Offices of Rural Health, and other rural stakeholders. Partners also contact CDC with concerns, which we share with the appropriate unit on the response. It is important for us to understand any challenges that rural communities face in addressing the pandemic, including access to healthcare, supplies, and vaccines as well as communicating the science about COVID-19 vaccines.

We know that a “one size fits all” approach is not going to work in rural areas. We also believe that it is useful for state and local jurisdictions to communicate with and learn from one another. To that end, CDC has been working with partners to identify examples of successes so they can be added to the RHIhub Rural COVID-19 Innovations section.

CDC recently announced an investment of $2.25 billion over two years to address COVID-19-related health disparities in communities that are high-risk and underserved, including rural communities. In addition to directly addressing COVID-19 activities, such as testing and developing prevention strategies, funds can be used to build public health infrastructure support.

Finally, CDC and USDA are collaborating on a 5-year, $9.9 million project leveraging the USDA Cooperative Extension System (CES) to provide immunization education and linkages to vaccination opportunities for people who live in rural areas and communities that are medically under-resourced.

What do rural communities need to know about COVID-19 vaccine distribution efforts? 

As of April 19, 2021, everyone 16 years of age or older^* is eligible to receive a COVID-19 vaccine at no cost. Vaccines are now more widely accessible in the United States. Each state makes its own plan for allocating vaccines to providers.

The Federal Retail Pharmacy Program is one effort to get the vaccine into the arms of every person in the U.S. The program is designed to use the strength and expertise of pharmacy partners to help rapidly vaccinate people across America. As a result, about 90% of people in the U.S. will soon have vaccine access through a community pharmacy within five miles of where they live — including in rural areas and some of the nation's communities most disproportionately impacted by COVID-19.

CDC and other federal partners, along with many states, are also engaging Federally Qualified Health Centers (FQHCs) to ensure the delivery of vaccines to under-resourced populations. For example, the Health Resources and Services Administration (HRSA) and CDC launched a program to directly allocate COVID-19 vaccines to HRSA-supported health centers. The program delivers vaccines to medically underserved communities and disproportionately affected populations through 950 health centers.

What is being done to ensure that vaccines are being distributed in a way that supports health equity, reaching rural populations and including people of color and tribal populations? 

CDC is actively working to ensure equity in COVID-19 vaccine distribution. CDC is committed to promoting fair access to health. Health equity is when everyone has the opportunity to be as healthy as possible. CDC has made available health equity considerations for racial and ethnic minority groups and is working with state, territorial, local, and tribal partners and community-serving organizations to ensure all public health actions address health disparities for all populations.

CDC is using our Social Vulnerability Index (SVI) to inform the COVID-19 vaccination program. The index was created to help emergency response planners and public health officials identify communities that would likely need support during an emergency. Using U.S. Census data, the index ranks each community in terms of socioeconomic status, household composition, race/ethnicity/language, and housing/transportation.

The SVI was adapted for the pandemic by the National Institutes of Health and is included on CDC's COVID-19 Data Tracker. The Data Tracker includes data on cases, deaths, and vaccination, including demographic trends. Where we are able to present county-level data, we use the 2013 NCHS Urban Rural Classification Scheme.

What are some of the challenges facing rural communities in getting vaccinated against COVID-19?

There are a number of challenges facing rural communities in terms of vaccination efforts. First, many communities are dealing with limited access to healthcare services, due to healthcare professional shortages or hospital closures. This undoubtedly puts a huge strain on existing healthcare professionals who remain in rural communities and creates a large burden on vaccination efforts. Additionally, public health services are often strained in rural places, with large regions supported by a single public health department.

Another challenge that rural communities face is limited access to broadband and technology. This has made online appointment scheduling very difficult for some rural residents. Many rural physicians have told CDC they have been calling their patients to answer questions, address concerns, and schedule appointments.

There are also issues of weather and transportation. Weather is a big concern. For example, blizzards, tornadoes, and hurricanes can hamper efforts to vaccinate. Also, in some rural communities, many people do not have access to reliable transportation or have to drive a long distance to get to healthcare centers or providers. CDC is aware of efforts to deliver vaccines to people where they live and work. This includes use of mobile units and community vaccination sites such as churches or large parking lots.

While the percentage of adults wanting to “wait and see” before getting vaccinated continues to decrease, this is a concern across the U.S., including in rural communities. Some people may want more information before making the choice to get vaccinated. Many factors influence vaccine decision-making, including personal risk of illness; how confident people are in vaccine safety and effectiveness; whether others in one's circle of friends, family, and coworkers are getting vaccinated; ease of finding a vaccination provider or scheduling an appointment; and political factors.

Communities can identify local trusted messengers to communicate key messages about the importance of vaccination and the safety and effectiveness of vaccines.

The potential for vaccine side effects remains the top concern among those who want to “wait and see” before getting vaccinated. Black and Hispanic adults wanting to “wait and see” are sometimes worried that they will not be able to get vaccinated in a place they know and trust. Some people are exposed to misinformation spread on social media, which undermines vaccine confidence, and others express feelings of distrust in government and the U.S. health system. CDC has developed vaccine confidence resources to address these challenges and build strong confidence in the vaccines within communities. Communities can identify local trusted messengers to communicate key messages about the importance of vaccination and the safety and effectiveness of vaccines.

What do rural communities need to consider in terms of their vaccine communication efforts?  

Each community will need multiple approaches and it is important to think creatively about both the messages themselves and the people delivering them. In rural communities, it is a good idea to use many communication platforms, such as radio and local newspaper articles. You can start with identifying people and platforms for the messaging. Who are the trusted leaders in your community? Where do people regularly get their information? This might mean articles in local newspapers, announcements at church services, or flyers in business and store windows. CDC provides considerations for community-based organizations to help protect individuals and communities against COVID-19.

For example, in some communities, local healthcare providers created YouTube videos to share. Physicians have told us they spend time educating patients about vaccines at all visits, even routine visits. Other healthcare providers have participated in vaccine town halls in their communities.

When most people are vaccinated, the virus has nowhere to go.

Sharing accurate health messages also continues to be a challenge. As previously mentioned, there is miscommunication and misinformation about the vaccine. Misinformation can lead to confusion and lack of trust, which in turn leads to vaccine hesitancy. Some surveys are showing that there are people still in the “I'll wait and see” category. We need as many people vaccinated as soon as possible. When most people are vaccinated, the virus has nowhere to go. And if it isn't spreading, it is harder for new variants to emerge.

CDC has a variety of communication resources that communities can use, as well as information on Vaccinating with Confidence on our website.

Finally, in some communities, there is confusion about the process of getting vaccinated. CDC has a website (no longer available online) with information on vaccine distribution. The website vaccines.gov allows people to find vaccination providers near them. People can also check with their health department or healthcare provider for more information.

What should people know about COVID-19 vaccines?

First, COVID-19 vaccines authorized and recommended for use in the United States are safe. More than 90% of doctors were vaccinated when they had the opportunity. Once people receive a vaccine, CDC continues to monitor how they are doing. CDC and FDA have a vaccine safety monitoring system called the Vaccine Adverse Event Reporting System (VAERS). There is also an app called v-safe (no longer available online), which allows people to report any side effects. An additional benefit of the app is that it can remind you about your second dose if you need one.

The vaccines are effective at preventing COVID-19. The vaccines also help keep you from getting seriously sick even if you do get COVID-19. While there is much we don't know, such as whether boosters will be needed, research shows that the vaccines prevent nearly all deaths and hospitalizations from COVID-19.

The process for developing and approving the vaccines was historic. But people should know this did not mean cutting corners on the research.

The process for developing and approving the vaccines was historic. But people should know this did not mean cutting corners on the research. The White House and various agencies in the federal government streamlined the regulations that are part of the approval process in order to get vaccines to people as quickly as possible.

CDC regularly updates its COVID-19 Vaccination section as we continue to learn about the vaccines.

What are you hearing from rural communities about how vaccination efforts are going? Are there success stories or lessons learned that rural communities have shared with you?

We have heard from partners, health departments, and providers about the creative ways in which they are addressing some of the challenges many rural communities face. We have consistently heard that, in many rural communities, people tend to trust the information they receive from local healthcare providers, faith leaders, and other local leaders. Physicians and other healthcare providers are having straightforward conversations in the community about the importance of getting vaccinated. In one community, the pastor of a church talked with his congregation about vaccines helping the entire community and allowed local providers to use the church as a vaccination site.

In another rural community, the medical officer for the Federally Qualified Health Center held town hall meetings where he answered questions from the community. He also went on various radio programs to talk about the vaccines. He learned of a mobile unit that the county health department had purchased and was able to use grant funding to purchase one for the FQHC.

Some regions are using an “all hands on deck” approach, in which community members help with large vaccination events. In other communities, some people are emerging as navigators and are helping people sign up for vaccination appointments.

In what ways might it be easier to vaccinate rural communities?

While we know there are challenges in many rural communities, we also know that there are plenty of strengths. Those strengths — a sense of connection and commitment to community, creativity, and a strong work ethic — can be vital during emergencies, like this pandemic.

While we know there are challenges in many rural communities, we also know that there are plenty of strengths. Those strengths — a sense of connection and commitment to community, creativity, and a strong work ethic — can be vital during emergencies, like this pandemic. The community can work to ensure that people have accurate information about the vaccines and how to get them. People can safely check in with neighbors. Civic organizations can help neighbors with physical limitations get to vaccination sites. That personal connection with trusted people is crucial.

CDC has several COVID-19 vaccination toolkits, including a toolkit for community-based organizations (no longer available online), with resources for educating communities on the importance of COVID-19 vaccination.

What resources does CDC have available to support rural vaccine education?

Our COVID-19 website has vaccine information for individuals and healthcare workers, including answers to commonly asked questions. We also developed a vaccine communication toolkit (no longer available online) for medical centers, pharmacies, and clinicians.

In addition to these vaccine-focused materials, CDC has developed many COVID-19 communication resources. These materials are also available in Spanish and other languages too.

Finally, CDC works with other federal partners that have their own specific resources. For example, the Federal Emergency Management Agency (FEMA) is working with federal, state, local, tribal, and territorial partners to help expand vaccination efforts. And the U.S. Health and Human Services Assistant Secretary for Preparedness and Response has many resources to use during disasters and emergencies. The site includes COVID-19 resources and materials for rural communities (use the search function to find them).

What else would you like to share?

You should get any COVID-19 vaccine that is available to you. Everyone 16 years of age or older^* is now eligible for the vaccine. All currently authorized and recommended COVID-19 vaccines are effective.

Hundreds of millions of people in the United States have received COVID-19 vaccines, and these vaccines have undergone the most intensive safety monitoring in U.S. history. This monitoring includes using both established and new safety monitoring systems to make sure that COVID-19 vaccines are safe. All COVID-19 vaccines were tested in clinical trials involving tens of thousands of people to make sure they meet safety standards. Adults of different races, ethnicities, and ages, including adults over the age of 65, participated in the clinical trials. You may have some side effects after vaccination, which are normal signs that your body is building protection. These reactions mean the vaccine is working to help teach your body how to fight COVID-19 if you are exposed. For most people, these side effects will last no longer than a day or two.

The use of Johnson & Johnson's Janssen vaccine was temporarily “paused” from April 13 to April 23. This is because the safety systems that make sure vaccines are safe received a small number of reports of a rare but severe type of blood clot with low platelets happening in people who got this vaccine. A review of all available data at this time shows that the J&J/Janssen vaccine's known and potential benefits outweigh the known and potential risks. CDC and FDA recommend the J&J/Janssen vaccine for adults 18 years or older. However, people, especially women younger than 50 years old, should be aware of the rare risk of this adverse event called “thrombosis with thrombocytopenia syndrome” (TTS) and that there are other COVID-19 vaccine options for which this risk has not been seen. For women 50 years or older and men of all ages, this adverse event is even rarer. CDC and FDA will continue to monitor the safety of all COVID-19 vaccines.

Please get vaccinated! As doses become available more widely, you should get a COVID-19 vaccine as soon you can.

^*Editor's note: The Pfizer-BioNTech COVID-19 Vaccine received emergency use authorization from the Food and Drug Administration for adolescents ages 12-15 on May 10^th. On May 12^th, the Advisory Committee on Immunization Practices (ACIP) adopted a recommendation endorsing the vaccine's safety for that age group.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.