How Puerto Rico’s vaccine drive turned into a success

The chief of the Puerto Rico Nationwide Guard was nonetheless coping with the aftermath of a 6.4-magnitude earthquake that displaced 1000’s of residents in January 2020 when island officers started listening to experiences of individuals falling unwell from the brand new coronavirus. As soon as once more, they turned to Guard Adjutant Normal José J. Reyes.

A lot of Reyes’ 37-year profession has been in emergency response mode — from 9/11 to the devastation of Hurricane Maria in 2017 to the earthquake — however he sees all of these occasions as preparation for this one: serving to to plan the island’s vaccination technique and oversee its rollout.

“That is the vital mission. It’s the mission of my life,” he instructed STAT.

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That mission has been so profitable it’s the envy of the mainland U.S. Puerto Rico has absolutely vaccinated the next share of its inhabitants than any state. As of final week, 2.3 million folks in Puerto Rico are absolutely vaccinated, or 89.7% of adults and 71.5% p.c of your entire inhabitants.

The three,500-square-mile island could appear an unlikely place to surpass all U.S. states and territories (apart from tiny Palau), being poorer than all different states and extra populous than equally profitable locations like Vermont — and whereas nonetheless reeling from pure disasters, fiscal crises, and political upheaval.

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Puerto Rico achieved this with late-summer mandates that drove up vaccination charges, but in addition by making pictures extensively accessible for months, even at seashores and bars. And in contrast to on the mainland, political polarization over the vaccine was unusual.

“The Republican/Democrat divide that’s driving variations in vaccine hesitancy within the U.S. doesn’t exist in PR,” mentioned Rafael Irizarry, a professor of utilized statistics on the Harvard T.H. Chan College of Public Well being and the Dana-Farber Most cancers Institute. That’s as a result of “standing” is the principle political divider on the island, and the 4 main events are proponents of vaccination, he mentioned. Irizarry thinks this may additionally clarify why vaccination charges are excessive in closely Democratic states, similar to Vermont, Massachusetts, Connecticut, and Rhode Island.

However the path to such excessive vaccination charges in Puerto Rico additionally took a lot planning and energy, which was led largely by the Nationwide Guard.

Reyes’ pandemic work began in early 2020. As vaccines went from a far-off chance to a actuality, the final was getting ready a plan. He would learn, at night time or within the morning, about vaccine logistics, together with the storage temperatures numerous producers would require to protect doses, and examine potential options. Reyes rapidly ordered 44 ultra-cold freezers from BioLife Options, which delivered them by mid-December 2020, when the primary vaccines could be out there. In complete, the freezers value lower than $300,000, he mentioned.

Puerto Rican officers developed an economical and versatile “hub-and-spoke” mannequin for vaccine distribution, BioLife COO and president Dusty Tenney instructed STAT. They created two foremost “hubs” for incoming vaccines: one within the northern a part of the island and one other within the south. 4 massive freezers able to storing 300,000 doses every have been positioned at services with backup mills (constant electrical energy can nonetheless be arduous to come back by post-Maria). From there, small, moveable freezers have been used to move as much as 5,000 doses at a time to clinics and different vaccination websites across the island. The concept was for Puerto Rico to have the ability to retailer 2.1 million vaccines at any given time, Reyes mentioned.

By the point the U.S. well being officers greenlit the Pfizer vaccine on Dec. 15, 2020, the island was prepared, the final mentioned. Doses left Pfizer warehouses for states and territories on December 14, and by midday the following day, all 64 main hospitals in Puerto Rico had acquired doses to inoculate well being care employees. It was the beginning of what could be a monthslong, 5 million-plus-dose endeavor.

In weekly conferences with Nationwide Guard generals in different states, Reyes shared Puerto Rico’s technique, and he mentioned a number of adopted comparable plans. The hub-and-spoke mannequin particularly was a option to deal with a public well being disaster in locations with hard-to-reach corners and different logistical challenges, similar to Veterans Affairs hospital campuses in North Carolina and sparsely populated states like South Dakota, Tenney mentioned.

From December to March, the Puerto Rico Division of Well being and Nationwide Guard established no less than a dozen mass vaccination websites throughout the island, began inoculating Puerto Rican vacationers arriving on the worldwide airport, leveraged the ubiquity of Walgreens shops and different pharmacies, and arranged occasions with massive employers, such because the police and the division of schooling. Knowledge present Walgreens alone administered greater than 926,000 doses as of final month, and the Puerto Rico Nationwide Guard delivered over half one million doses.

In late April and early Could, as pictures turned extra extensively out there, Puerto Rico’s operation was producing a excessive of practically 300,000 vaccinations per week.

A lot of the eligible inhabitants had been inoculated by late July that it was not cost-effective to keep up the massive, closely staffed mass vaccination websites so the Guard shut them down, Reyes mentioned. The island is now utilizing a focused strategy, together with going door-to-door and visiting nursing properties, for the 50,000 to 70,000 doses acquired each week. Officers administer 99% of the vaccines they obtain, mentioned Dr. Iris Cardona, chief medical officer of the Puerto Rico Division of Well being.

In August, as vaccination charges slumped and the Delta variant was driving an exponential improve in new circumstances, the federal government issued vaccine mandates for colleges, public workers, and a few elements of the non-public sector, together with eating places. That jolted Puerto Rico’s vaccination charges up previous New England’s, mentioned Irizarry, who has been monitoring Covid-19 in Puerto Rico as a part of a scientific coalition convened by Gov. Pedro Pierluisi.

Irizarry mentioned he thinks the mandates had the most important influence on vaccination charges, adopted by the provision of pictures (there at the moment are 975 vaccine suppliers on the island, and shortly to be 300 only for kids). Broad cohesion amongst political leaders and their public well being messaging additionally helped, he mentioned.

The trail to 70% vaccinated in Puerto Rico: a temporal visualization.

Two observations:
– For every age group, the charges are quickest proper after vaccines are made out there, however they decelerate dramatically at round 50-60%
– Vaccine mandates clearly speed up vaccination charges. pic.twitter.com/CtzqjdemqY

— Rafael Irizarry (@rafalab) October 25, 2021

When requested whether or not he thinks apolitical messaging was key to the island’s success with vaccination efforts, Reyes mentioned he sees the Nationwide Guard as an necessary and credible middleman. “I definitely imagine that the folks of Puerto Rico know Normal Reyes by now, dealing with emergency responses in Puerto Rico. I’m an Military officer, I’m not a politician, so that they know if I used to be behind the technique, there was no politics concerned,” he mentioned.

Nonetheless, the mandates confronted authorized challenges in native and federal courts, a number of of which have upheld the general public well being directives and one in every of which remains to be excellent, Cardona mentioned.

“It shouldn’t be your first initiative, however typically you need to handle to place in place some mandates with a purpose to make it simpler for folks to determine,” she mentioned.

Puerto Rican officers additionally launched a strong media marketing campaign, utilizing distinguished medical doctors, well being employees, actors, and others to advertise vaccination to varied slices of the inhabitants on TV and radio and in newspapers. First responders, mayors of all 78 municipalities on the island, and leaders from over a dozen spiritual denominations have been additionally recruited to unfold the phrase.

“After the service on a Sunday morning, we have been there to vaccinate folks after ending church,” Reyes mentioned.

When folks below 30 have been driving Covid-19 circumstances, the final met with dozens of mayors to determine how they might goal the locations the place younger folks convened. Wherever younger adults met and mingled — bar-hopping at La Placita de Santurce in San Juan or enjoyable on Luquillo Seashore, for instance — is the place Reyes needed to be.

“We ended up vaccinating at these areas on Thursday nights and Friday nights. We weren’t giving beers to them, however we have been there to orient them and to vaccinate them,” he mentioned. “And we began going via the completely different seashores. We vaccinated on the Fourth of July in lots of seashores right here in Puerto Rico. That was a part of the technique. It’s a navy mentality of, ‘Get it executed.’”

If “getting it executed” meant Reyes strolling in full uniform with an area official alongside a seaside within the lifeless warmth of summer season, he did that.

The rollout wasn’t with out its issues, although. Like in different states and territories, native authorities typically disobeyed the phased approach recommended by federal officials, or well-connected Puerto Ricans expedited vaccinations for themselves and their kinfolk, the Centro de Periodismo Investigativo discovered. The Nationwide Guard was one of many businesses that vaccinated contractors earlier than some weak populations, although Reyes defended the observe to CPI reporters. Inequitable vaccine access was also a problem, with poorer areas lagging behind wealthier ones, a separate CPI evaluation discovered. Cardona mentioned she believed the info have been skewed as a result of many well being care and frontline employees resided in bigger municipalities, and so they had entry to vaccines first.

To mitigate these inequities, the well being division labored with neighborhood well being facilities to arrange greater than 60 clinics throughout Puerto Rico to vaccinate weak and distant populations. The company, which has beefed up its employees from 15 to 50 folks, additionally did multi-day pop-up vaccination clinics in all 78 municipalities, together with on the japanese islands of Vieques and Culebra.

Adults over 85 and younger folks ages 20 to 29 have been essentially the most difficult to succeed in, Cardona instructed STAT, however a well being division door-knocking marketing campaign helps.

Reyes sees Puerto Rico assembly his purpose of vaccinating 90% of the inhabitants by the top of November, bolstered by the vaccination of an estimated 200,000 kids ages 5 to 11.

Early on within the pandemic, some teachers theorized in a Lancet commentary that Caribbean nations would possibly fare higher throughout Covid-19 as a result of folks have been used to states of emergency attributable to pure disasters, and subsequently extra keen to observe authorities mandates. It is sensible to obey a stay-at-home order when an infinite hurricane is en route, so folks would act the identical method throughout an invisible disaster just like the virus, the considering went.

What has really performed out is “a posh state of affairs after all, and Caribbean variety makes generalizations doubly awkward,” lead creator Ian Hambleton instructed STAT, noting that Puerto Rico was not included in his evaluation. “I believe our message of compliance with stay-at-home orders stays broadly true. Acceptance of vaccination is one other matter totally,” mentioned Hambleton, a professor of biostatistics on the College of the West Indies.

However Reyes thinks there would possibly nonetheless be a kernel of fact to the thought in Puerto Rico.

“Experiencing so many pure disasters right here in Puerto Rico for the previous 4 years, beginning with Hurricanes Irma, Maria, then the earthquakes, then the pandemic, tropical storms, wildfires … the message has [gotten] to the inhabitants that you might want to be ready,” he mentioned.