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Getting COVID-19 vaccines to rural Americans is harder than it looks – but there are ways to lift the barriers

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Clinical Assistant Professor, Pharmacy Practice, Binghamton University, State University of New York
Professor of Rural Nursing, Binghamton University, State University of New York
The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

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The enormous job of vaccinating the nation is underway, but for rural Americans, getting a COVID-19 vaccine becomes harder the farther they are from urban centers.
The current vaccines’ cold storage requirements and shipping rules mean many rural hospitals can’t serve as vaccination distribution hubs. That can leave rural residents – about 20% of the U.S. population – traveling long distances, if they’re able to travel at all.
Getting the word to rural residents about when they can be vaccinated isn’t easy either, and the extraordinary amount of misinformation downplaying the risk of the coronavirus this past year has had an impact on rural residents’ willingness to get the vaccine.
We work in rural health care settings and have been examining the barriers to health care for these patients to find ways to ensure health and safety.
The first two authorized vaccines – one made by Pfizer and BioNTech and the other by Moderna – are mRNA vaccines. It’s a new type of vaccine that uses the molecular instructions for building virus proteins rather than 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, and for now, vaccines are being delivered only in large batches.
The Pfizer vaccine is shipped in increments of 975 doses, which creates a challenge for small hospitals. Urban areas will be able to quickly distribute those doses, but finding enough patients to vaccinate quickly in rural areas may prove more difficult.
Moderna’s vaccine is somewhat more manageable, with a minimum order of 100 doses.
Both vaccines also require two doses per person, with the second dose of Pfizer’s vaccine given 21 days later and Moderna’s 28 days later.
As a result, the vaccine distribution efforts will favor hubs that cater to more populated areas to avoid wasting any vaccine or leaving patients unable to get their second dose.
Cold storage is another challenge, since small hospitals are less likely to have expensive freezers. The Pfizer vaccine must be stored at minus 94 degrees Fahrenheit (minus 70 Celsius) and Moderna’s at minus 4 Fahrenheit. There are limits on how many times the vaccine shipping containers can be opened and how quickly the vaccines must be distributed. Once thawed and prepared, the Pfizer vaccine must be used within five days and Moderna’s within 30 days.
Each patient must receive both doses of the vaccine from the same manufacturer to ensure safety and effectiveness, adding to the challenge. Manufacturers have included personal dosing cards for patients to carry with them to help.
Rural America already has difficult barriers to health care access.
It has fewer health care providers serving a more geographically diverse population than in metropolitan communities. And in many of these areas, rural hospitals have been closing at an alarming rate, leaving people to travel farther for care. The population is also older. Public transportation that could help poor or elderly residents reach hospitals is rare, and distance and geography, such as mountain roads, can mean driving to those sites takes time.
Getting accurate information about the vaccine and how to receive it into rural areas has also proved difficult. Many rural counties still have limited access to broadband internet connections, smartphone service and other technologies. That often means 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 don’t not seem to have specific plans on how to inform their residents about how and when each person can get the vaccine, let alone specific plans for actually giving it. They often rely just on local press releases that many residents never see.
Rural nonprofit health care organizations have tried to bridge that gap and improve rural communications about vaccines and the pandemic. Care Compass Network, which coordinates organizations across southern New York, has offered educational webinars with the latest information about the virus and the vaccines, for example. But there is still much work to do.

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Rural Americans’ views on vaccines are influenced by media and word of mouth, politics and religion, as well as previous experience with vaccinations and, perhaps most importantly, the difficulty of accessing health care.
In a survey conducted by the Kaiser Family Foundation in December, about 35% of rural Americans said they probably or definitely would not get the vaccine, higher than the 27% nationwide.
Getting enough of the U.S. vaccinated to eventually end the pandemic will require more work in all of these areas. That includes improving shipping and storage processes so orders can be broken up and distributed to smaller hospitals, distributing more vaccine doses, and improving communication.
With Moderna’s vaccine arriving in smaller batches and not requiring such low temperatures for stability, it may prove to be more accessible for rural areas. Utah has already taken advantage of those characteristics to get initial doses to smaller hospitals and has started vaccinating health care providers. Pfizer has said it may be able to offer smaller batches by April.
Other vaccines on the horizon are also expected to have less stringent storage requirements and may potentially be delivered in one shot. The British government on Dec. 30 authorized one of them, a two-dose vaccine made by AstraZeneca that can be stored in a normal refrigerator for six months. U.S. officials are awaiting more testing on it, however, and don’t expect authorization for U.S. use until April.
The falling number of rural hospitals also remains a challenge for getting vaccines to patients. Allowing community pharmacies to offer the vaccine – particularly if independent pharmacies are included – could eventually help expand the distribution network in rural areas.
This article was updated Dec. 30 with the U.K.‘s AstraZeneca vaccine authorization.
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How to stay safe with a fast-spreading new coronavirus variant on the loose

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Bayard D. Clarkson Distinguished Professor of Mechanical and Aeronautical Engineering, Clarkson University
Associate Professor of Mechanical Engineering, Clarkson University
Suresh Dhaniyala receives funding from National Science Foundation and NY State Energy Research and Development Authority.
Byron Erath receives funding from the National Institutes of Health, the National Science Foundation, and the Empire State Development's Division of Science, Technology and Innovation (NYSTAR)

Clarkson University provides funding as a member of The Conversation US.
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A fast-spreading variant of the coronavirus that causes COVID-19 has been found in at least 20 states, and people are wondering: How do I protect myself now?
We saw what the new variant, known as B.1.1.7, can do as it spread quickly through southeastern England in December, causing case numbers to spike and triggering stricter lockdown measures.
The new variant has been estimated to be 50% more easily transmitted than common variants, though it appears to affect people’s health in the same way. The increased transmissibility is believed to arise from a change in the virus’s spike protein that can allow the virus to more easily enter cells. These and other studies on the new variant were released before peer review to share their findings quickly.
Additionally, there is some evidence that patients infected with the new B.1.1.7 variant may have a higher viral load. That means they may expel more virus-containing particles when they breathe, talk or sneeze.
As professors who study fluid dynamics and aerosols, we investigate how airborne particles carrying viruses spread. There is still a lot that scientists and doctors don’t know about the coronavirus and its mutations, but there are some clear strategies people can use to protect themselves.

The SARS-CoV-2 variants are believed to spread primarily through the air rather than on surfaces.
When someone with the coronavirus in their respiratory tract coughs, talks, sings or even just breathes, infectious respiratory droplets can be expelled into the air. These droplets are tiny, predominantly in the range of 1-100 micrometers. For comparison, a human hair is about 70 micrometers in diameter.
The larger droplets fall to the ground quickly, rarely traveling farther than 6 feet from the source. The bigger problem for disease transmission is the tiniest droplets – those less than 10 micrometers in diameter – which can remain suspended in the air as aerosols for hours at a time.
With people possibly having more virus in their bodies and the virus being more infectious, everyone should take extra care and precautions. Wearing face masks and social distancing are essential.
Spaces and activities that were previously deemed “safe,” such as some indoor work environments, may present an elevated infection risk as the variant spreads.
The concentration of aerosol particles is usually highest right next to the individual emitting the particles and decreases with distance from the source. However, in indoor environments, aerosol concentration levels can quickly build up, similar to how cigarette smoke accumulates within enclosed spaces. This is particularly problematic in spaces that have poor ventilation.
With the new variant, aerosol concentration levels that might not have previously posed a risk could now lead to infection.

1) Pay attention to the type of face mask you use, and how it fits.
Most off-the-shelf face coverings are not 100% effective at preventing droplet emission. With the new variant spreading more easily and likely infectious at lower concentrations, it’s important to select coverings with materials that are most effective at stopping droplet spread.
When available, N95 and surgical masks consistently perform the best. Otherwise, face coverings that use multiple layers of material are preferable. Ideally, the material should be a tight weave. High thread count cotton sheets are an example. Proper fit is also crucial, as gaps around the nose and mouth can decrease the effectiveness by 50%.
2) Follow social distancing guidelines.
While the current social distancing guidelines are not perfect – 6 feet isn’t always enough – they do offer a useful starting point. Because aerosol concentrations levels and infectivity are highest in the space immediately surrounding anyone with the virus, increasing physical distancing can help reduce risk. Remember that people are infectious before they start showing symptoms, and they many never show symptoms, so don’t count on seeing signs of illness.
3) Think carefully about the environment when entering an enclosed area, both the ventilation and how people interact.
Limiting the size of gatherings helps reduce the potential for exposure. Controlling indoor environments in other ways can also be a highly effective strategy for reducing risk. This includes increasing ventilation rates to bring in fresh air and filtering existing air to dilute aerosol concentrations.
On a personal level, it is helpful to pay attention to the types of interactions that are taking place. For example, many individuals shouting can create a higher risk than one individual speaking. In all cases, it’s important to minimize the amount of time spent indoors with others.
The CDC has warned that B.1.1.7 could become the dominant SARS-CoV-2 variant in the U.S. by March. Other fast-spreading variants have also been found in Brazil and South Africa. Increased vigilance and complying with health guidelines should continue to be of highest priority.
[Deep knowledge, daily. Sign up for The Conversation’s newsletter.]
This story was updated Jan. 18 with latest CDC count and map showing B.1.1.7 cases now found in 20 states.
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How to stay safe with a new fast-spreading coronavirus variant on the loose

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Bayard D. Clarkson Distinguished Professor of Mechanical and Aeronautical Engineering, Clarkson University
Associate Professor of Mechanical Engineering, Clarkson University
Suresh Dhaniyala receives funding from National Science Foundation and NY State Energy Research and Development Authority.
Byron Erath receives funding from the National Institutes of Health, the National Science Foundation, and the Empire State Development's Division of Science, Technology and Innovation (NYSTAR)

Clarkson University provides funding as a member of The Conversation US.
View all partners
A fast-spreading variant of the coronavirus that causes COVID-19 has been found in at least 10 states, and people are wondering: How do I protect myself now?
We saw what the new variant, known as B.1.1.7, can do as it spread quickly through southeastern England in December, causing case numbers to spike and triggering stricter lockdown measures.
The new variant has been estimated to be 50% more easily transmitted than common variants, though it appears to affect people’s health in the same way. The increased transmissibility is believed to arise from a change in the virus’s spike protein that can allow the virus to more easily enter cells. These and other studies on the new variant were released before peer review to share their findings quickly.
Additionally, there is some evidence that patients infected with the new B.1.1.7 variant may have a higher viral load. That means they may expel more virus-containing particles when they breathe, talk or sneeze.
As professors who study fluid dynamics and aerosols, we investigate how airborne particles carrying viruses spread. There is still a lot that scientists and doctors don’t know about the coronavirus and its mutations, but there are some clear strategies people can use to protect themselves.
The SARS-CoV-2 variants are believed to spread primarily through the air rather than on surfaces.
When someone with the coronavirus in their respiratory tract coughs, talks, sings or even just breathes, infectious respiratory droplets can be expelled into the air. These droplets are tiny, predominantly in the range of 1-100 micrometers. For comparison, a human hair is about 70 micrometers in diameter.
The larger droplets fall to the ground quickly, rarely traveling farther than 6 feet from the source. The bigger problem for disease transmission is the tiniest droplets – those less than 10 micrometers in diameter – which can remain suspended in the air as aerosols for hours at a time.
With people possibly having more virus in their bodies and the virus being more infectious, everyone should take extra care and precautions. Wearing face masks and social distancing are essential.
Spaces and activities that were previously deemed “safe,” such as some indoor work environments, may present an elevated infection risk as the variant spreads.
The concentration of aerosol particles is usually highest right next to the individual emitting the particles and decreases with distance from the source. However, in indoor environments, aerosol concentration levels can quickly build up, similar to how cigarette smoke accumulates within enclosed spaces. This is particularly problematic in spaces that have poor ventilation.
With the new variant, aerosol concentration levels that might not have previously posed a risk could now lead to infection.

1) Pay attention to the type of face mask you use, and how it fits.
Most off-the-shelf face coverings are not 100% effective at preventing droplet emission. With the new variant spreading more easily and likely infectious at lower concentrations, it’s important to select coverings with materials that are most effective at stopping droplet spread.
When available, N95 and surgical masks consistently perform the best. Otherwise, face coverings that use multiple layers of material are preferable. Ideally, the material should be a tight weave. High thread count cotton sheets are an example. Proper fit is also crucial, as gaps around the nose and mouth can decrease the effectiveness by 50%.
2) Follow social distancing guidelines.
While the current social distancing guidelines are not perfect – 6 feet isn’t always enough – they do offer a useful starting point. Because aerosol concentrations levels and infectivity are highest in the space immediately surrounding anyone with the virus, increasing physical distancing can help reduce risk. Remember that people are infectious before they start showing symptoms, and they many never show symptoms, so don’t count on seeing signs of illness.
3) Think carefully about the environment when entering an enclosed area, both the ventilation and how people interact.
Limiting the size of gatherings helps reduce the potential for exposure. Controlling indoor environments in other ways can also be a highly effective strategy for reducing risk. This includes increasing ventilation rates to bring in fresh air and filtering existing air to dilute aerosol concentrations.
On a personal level, it is helpful to pay attention to the types of interactions that are taking place. For example, many individuals shouting can create a higher risk than one individual speaking. In all cases, it’s important to minimize the amount of time spent indoors with others.
The CDC has warned that B.1.1.7 could become the dominant SARS-CoV-2 variant in the U.S. by March. Other fast-spreading variants have also been found in Brazil and South Africa. Increased vigilance and complying with health guidelines should continue to be of highest priority.
[Deep knowledge, daily. Sign up for The Conversation’s newsletter.]
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The great polio vaccine mess and the lessons it holds about federal coordination for today’s COVID-19 vaccination effort

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Associate Professor of International Business and Strategy at the D'Amore-McKim School of Business, Northeastern University
Bert Spector does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
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I nervously fell into a long line of fellow first graders in the gymnasium of St. Louis’ Hamilton Elementary School in the spring of 1955. We were waiting for our first injection of the new polio vaccine.
The National Foundation for Infantile Paralysis – with money raised through its annual March of Dimes campaign – had sponsored field tests for a vaccine developed by Jonas Salk. The not-for-profit had acquired sufficient doses to inoculate all the nation’s first and second graders through simultaneous rollouts administered at their elementary schools. The goal was to give 30 million shots over three months.
Now, more than six decades later, attention focuses on the rollout of two COVID-19 vaccines, following their emergency use authorization by the U.S. Food and Drug Administration. States have begun to administer them in a rocky and frustratingly slow delivery process – while hundreds of thousands of new cases continue to be diagnosed daily in the U.S.
While not necessarily comforting, it is useful to recognize that the early days and weeks of mass distribution of a new medication, particularly one that is intended to address a fearful epidemic, are bound to be frustrating. Only after examining the complex polio vaccine distribution process as documented in papers collected in the Dwight D. Eisenhower Presidential Library did I come to understand how partial my childhood memories actually were.
After I received my polio shot, I remember my parents’ relief.
The polio virus causes flu-like symptoms in most people who catch it. But in a minority of those infected, the brain and spinal cord are affected; polio can cause paralysis and even death. With the distribution of Salk’s vaccine, the much-feared stalker of children and young adults had seemingly been tamed. Within days, however, the initial mass inoculation program went off the rails.
Immediately following the government’s licensing of the Salk vaccine, the National Foundation for Infantile Paralysis contracted with private drug companies for US$9 million worth of vaccine (around $87 million today) – about 90% of the stock. They planned to provide it free to the country’s first and second graders. But just two weeks after the first doses were administered, the Public Health Service reported that six inoculated children had come down with polio.
As the number of such incidents grew, it became clear that some of the shots were causing the disease they were meant to prevent. A single lab had inadvertently released adulterated doses.
After considerable fumbling and outright denial, Surgeon General Leonard Steele first pulled all tainted vaccine off the market. Then, less than a month after the initial inoculations, the U.S. shut down distribution entirely. It wasn’t until the introduction of a new polio vaccine in 1960, created by Albert Sabin, that public trust returned.
This story offers several lessons relevant to the COVID-19 vaccine distribution just now getting rolling.
First, federal coordination of an emergent lifesaving medical product is critical.
The federal government had declined to play an active oversight and coordination role for the polio vaccine, but still wanted the credit. The federal Department of Health, Education and Welfare (now Health and Human Services) offered no plan for distribution beyond the privately funded school-based program.
The department waited a full month after the vaccine was first administered before bringing together a permanent scientific clearance panel. That delay had less to do with formal procedures than with the ideological opposition of Health, Education and Welfare Secretary Oveta Culp Hobby.
Hobby was a political appointee who had taken office just months before the vaccine was approved. Her reluctance to involve the federal government in matters that she believed were best left in private hands – and her oft-stated fear of “socialized medicine” – meant that safety checks would be left to the private labs producing the vaccine. The results immediately caused dire problems and even avoidable deaths.
Second, the polio vaccine distribution process demonstrated how vital it is for the federal government to act in ways deserving of public trust.
In those hopeful first few weeks of the polio vaccine distribution, those of us lining up for shots had little to fear beyond the sting of an injection. That changed quickly.
Once some children had in fact been harmed by the shot, obfuscation by government officials, clumsy explanations and delayed responses engulfed the entire production and distribution process in confusion and suspicion. Trust in the government and the vaccine eroded accordingly. Gallup polls found that by June 1955, almost half of the parents who responded said they would not take any further vaccine shots – and the full regimen of polio inoculation required three doses. In 1958, some drug companies halted production, citing “public apathy.” It wasn’t surprising to see a startling upsurge in polio in 1959, doubling cases from the previous year.
Today, with COVID-19 already highly politicized – polls suggest that a minority of Americans will decline to take any vaccine – it is critical to administer an effective vaccine delivery program in a manner that builds trust rather than undermines it.
Scattered reports of allergic reactions to the COVID-19 vaccine have generated not the denials of the Eisenhower administration but rather honest and realistic responses from the Centers for Disease Control and Prevention. Particularly for vaccines that require multiple inoculations – both Pfizer and Moderna vaccines require two shots administered with a 21- or 28-day gap – mass inoculations will require not just an initial willingness to get the first dose but the maintenance of trust sufficient to get people back for the followup.
There are significant differences in the social-political contexts of the era in which the polio vaccine was distributed and today, including the nature and threat of the two diseases and the technologies of the vaccines. But time and again, the COVID-19 pandemic has revealed disconcerting parallels with mistakes made in the past. The good news is vaccination works – no case of polio has originated in the U.S. since 1979.
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