Montana’s playbook for moving the needle on vaccinations

Every time the Flathead City-County Health Department holds a COVID-19 vaccine clinic, Joe Russell does his best to be there. As the county health officer, he’s not in charge of distributing the shots. His goal is to connect with county residents nonetheless.

“I literally try to be at the clinic every time we operate,” Russell said in a recent phone call. “To me, with the pandemic, it’s the most important thing we can do, to vaccinate people. And I don’t think it’s my role to sit on my butt.” When people come into the clinic, he said, “I want them to understand that I want them to be vaccinated.”

Russell came out of retirement to return to the health department after his previous 30-year tenure. He said his presence at the vaccine clinics is “more of a messaging strategy” to boost momentum in the fight against the coronavirus.

As Montana nears six months of vaccine distribution — first to health workers, then to particularly vulnerable residents, now to nearly anyone who wants a shot — demand for immunizations is dropping. Mass vaccination clinics at county fairgrounds have curbed hours of operation or are considering closing altogether. County and state officials, along with hospitals and health care clinics, are experimenting with mobile vaccination clinics or walk-up availability at community events and even breweries. The state’s Department of Public Health and Human Services has budgeted $1.5 million for public service announcements on radio and television stations, along with digital advertising, all with the same goal: convincing more Montanans to get the vaccine and bring their friends, family and coworkers along.

The reason for the substantial drop-off, health officials say, is far from universal. People may have unforgiving schedules or limited transportation to a vaccine clinic. Others may have unresolved questions about how vaccines will interact with specific health issues. With reports of new infections in the state decreasing, perhaps some people are simply feeling a lack of urgency. 

Health officials, however, are not lowering their expectations. In Flathead County, Russell said, 75% of elderly residents have been vaccinated. Consider the eligible population of roughly 84,000 as a whole, however, and the inoculation rate drops to 31%. Russell wants to see that number climb — if his department can figure out how to reach more people.

“We do believe another model is necessary,” Russell said. “We just don’t know how much demand is there.”

VACCINATION BY THE NUMBERS

Overall, Montana has delivered approximately 750,000 doses of vaccine, bringing the state’s total vaccination rate to roughly 34%. Some of the state’s counties, such as those encompassing tribal nations, report substantially higher rates of vaccinations for eligible populations. Others, including a handful of rural locations in eastern Montana, show numbers that are notably low — fewer than 300 people fully immunized, for example, out of more than 1,000 eligible residents in a single county.

Nationally, Montana is neither at the front of the pack nor lagging far behind, according to data compiled by the Centers for Disease Control and Prevention. Maine, Connecticut and Vermont report among the highest rates of inoculation, with percentages in the low-to-mid 40s. On the other end of the spectrum, Utah, Alabama and Mississippi hover around 25%. Demand in Montana is not so low that the state has begun declining its full federal vaccine allocation, as some other states have done.

“From my standpoint, when you look at us compared to the rest of the country, we’re doing a really good job of getting the vaccine out there,” DPHHS director Adam Meier said in a recent interview with MTFP. “We’re not really an outlier.”

Still, pressure remains on health officials to increase numbers across the board. President Joe Biden has set a national goal of vaccinating 70% of adults by July 4, a total of 160 million people. On Monday, the Food and Drug Administration expanded emergency use authorization for the Pfizer vaccine to be distributed to people between the age of 12 and 15, adding a new hurdle and opportunity for public health administrators. 

“You hear people say ‘all politics are local,’ but really, all immunity is local, too … If a community has a low vaccination rate, they risk spreading it to the rest of the state, the rest of the country.”

Yellowstone County HEALTH OFFICER JOHN FELTON

More importantly, the push to vaccinate more people is fueled by a desire to head-off another spike in cases. The virus has already killed nearly 1,600 Montanans after a devastating winter surge. New variants from Brazil and India have been detected in the state, adding to the number of strains that concern COVID-19 researchers. The current lull in Montana’s reported cases, health officials say, does not mean that the danger is gone.

“It will be back,” said John Felton, health officer in Yellowstone County, about the coronavirus. “I think we need to continue to encourage people to get vaccinated, continue to make it as easy as possible for people to get vaccinated.”

As in other counties, Felton has seen a significant decrease in recent demand for the vaccine — appointments are down 70% compared to a month ago. Part of that decline makes sense, he said, after an initial surge when Gov. Greg Gianforte opened vaccine access to anyone age 16 and older at the beginning of April. But Felton is also quick to point out a number of other contributing variables, including the slump in reported COVID-19 cases. Fewer positive tests may feed into a lack of fear and urgency.

Reactive thinking about immunization, Felton said, risks setting Montana and the rest of the country up for more harm. 

“You hear people say ‘all politics are local,’” Felton said. “But really, all immunity is local, too … If a community has a low vaccination rate, they risk spreading it to the rest of the state, the rest of the country,” he said, referencing Montana’s high level of tourism. 

“This virus is going to be around. It’s going to continue to mutate, it’s going to continue to change,” Felton said. “So everything we can do to slow it or to protect people is going to help. Because we’re not going to outlast it.”

MEASURING LACK OF INTEREST

For public health officials, part of the difficulty of advancing vaccinations is a lack of clarity about why sign-ups are down in the first place. Meier, of DPHHS, referenced the brief pause of the one-shot Johnson & Johnson vaccine as a setback for the state’s numbers. Officials in the department agree that complacency linked to the low numbers of reported infections, as Felton pointed out, is another possible factor. 

Health researchers and authorities also acknowledge that a portion of the population is entrenched in opposition to vaccines, sometimes fueled by medical skepticism or conspiracy theories, and is unlikely to ever be convinced to get vaccinated. People who oppose broad requirements for FDA-approved vaccines in schools and workplaces received a spotlight this year at the Montana Legislature, where several bills were debated and some ultimately passed. One policy, signed into law by the governor with additional amendments, broadly restricts employers, including hospitals and nursing homes, from requiring their employees to receive any vaccine.

“That’s what we’re going to keep doing, listening to people. And I think over time, as millions of people continue to get this vaccine and we see the benefits of it, I think that some of that will break down. We’re just going to keep putting our heads down and working on it.”

Gallatin County Health Officer Matt Kelley

“People are afraid. They’re concerned. They’re facing the choice of being vaccinated or terminated if they don’t have vaccinations required by their employer or the state,” said Sen. Tom McGillvray, R-Billings, in Senate floor comments in favor of HB 702. “This is just the beginning of the invasion of our privacy and our fundamental constitutional rights.”

When it comes to inoculations for COVID-19, national surveys have recently indicated that vaccine opposition is more present in rural and Republican communities. Another analysis found that vaccine skepticism was on average higher in counties that supported former President Donald Trump in the 2020 election. Federal data from March estimated that 20% to 30% of adults in Montana may be skeptical about receiving the vaccine. Local officials are hearing about that hesitancy in their own communities, a phenomenon that can test their patience as they work to protect residents.

“I’ve had people who’ve come to the clinic in tears because they’ve lost their spouse to this disease,” said Russell, the Flathead County health officer. “And we have knuckleheads — I shouldn’t use that word. We have people who don’t believe this is an important disease to combat.”

During a Senate floor debate on the vaccine requirement bill last month, one lawmaker alluded to a conspiracy theory about microchips in vaccines — a theory Gallatin County Health Officer Matt Kelley stressed has been categorically debunked by medical experts. Kelley, who will be leaving his job at the county next month to become CEO of the Montana Public Health Institute, added that while those stories have been “out there for years,” he finds the notion “a head-scratcher.” His office will continue to respond the way it always has, he said, by listening to people and providing them with the best information it can.

“That’s what we’re going to keep doing, listening to people,” Kelley said. “And I think over time, as millions of people continue to get this vaccine and we see the benefits of it, I think that some of that will break down. We’re just going to keep putting our heads down and working on it.”

Russell and other public health workers stress the importance of having an open-door policy to answer questions about the vaccines, while reiterating the efficacy and rigorous assessments the vaccines went through. In the big picture, however, authorities accept that opposition to vaccines is a normal part of public health outreach. They also say it shouldn’t consume the rest of their efforts.

“We see this with pretty much all the vaccines we deal with. There’s always a segment of the population that’s concerned about the vaccine for one reason or another,” said Jim Murphy, who heads the state’s infectious disease bureau. 

Where the focus of DPHHS and local health authorities is better spent, Murphy explained, is on the people in the middle — those who are more open to receiving the vaccine but “didn’t go out of their way to get it.” 

When it comes to answering questions or swaying hesitant minds, Kelley acknowledges that there are limits to what county officers can do. The CDC, election officials and local health officers can continue hammering the message that the vaccine is safe and effective and encouraging the public to turn to reputable sources for more information, Kelley said. But for people who remain wary, he recommends they consult their own physician.

“We know that people choose their health care providers. They have trust in them,” Kelley said.

Above all, health officials are stressing the need for state, local and private health interests to champion the vaccines and change how doses are distributed. In practice, that could mean expanding clinic hours to reach people before or after they get off work and increasing the number of pharmacies that administer doses. Following direction from the federal government, primary care providers at individual clinics and hospitals will also turn into access points, which may help build confidence among patients who want their questions answered by a trusted medical source. Local health departments can also start working with providers to send out mobile vaccination units and pop-up clinics for major worksites, schools and community events. 

All of those tactics, authorities hope, can push local trends in an upward direction — even if each strategy yields only a small number of distributions.

“Those numbers add up over time,” Murphy said.

MONTANA’S MESSAGE

The effort to increase Montana’s vaccination rate is also a priority of the executive branch. Gov. Gianforte has been supporting the initiative, casting it as an essential part of boosting Montana’s economy. In press conferences since he took office, Gianforte routinely urged Montanans to sign up for available appointments, making sure to reiterate a pro-vaccine message: The shots are safe, effective and essential for returning to a pre-pandemic way of life. He allowed members of the news media to attend when he got his first shot, and has retained several top officials and emergency responders from former Gov. Steve Bullock’s administration to help coordinate the pandemic strategy.

Gianforte’s actions, however, also indicate the governor is walking a fine line that reflects the now-political nature of public health measures. Early in his tenure, he repealed the statewide mask requirements for counties with more than four confirmed cases of COVID-19. During the legislative session, he supported and signed several policies that weaken the powers of local public health authorities, including their ability to enforce mask mandates and other preventative measures. When it comes to vaccines, Gianforte signed HB 702, but added language that allows nursing homes to comply with employee vaccine requirements if mandated by the federal Centers for Medicare and Medicaid.

Aside from the policies green-lit by the executive branch, state government is boosting its own messaging meant to increase vaccine confidence. Building on last year’s push for mask wearing and social distancing, the state began broadcasting radio public service announcements in March that point listeners to the DPHHS website for vaccine and appointment information. Near the end of April, the state also produced television PSAs that it intends to continue for several months. It’s now looking to increase the reach of those messages with more partnerships. Town Pump, for example, has recently agreed to start airing the broadcasts at their gas pumps across the state.

Officials said the tone and content of the messages was narrowed after rounds of polling to evaluate reactions. If responses indicated Montana residents were concerned about cost, the state’s messaging would reflect that the vaccine is free to receive. When hesitation came up around safety, PSAs would seek to assuage that fear by touting the vaccines as safe and effective. Those same messaging tactics, DPHHS officials said, are being echoed and amplified by local public health messaging strategies.

“We are working hand in glove with our local counterparts to use the messaging that’s working,” Meier said.

If the state’s strategy, along with those of city and county health officials, is effective, the proof will show up in the trendlines. While some parts of the state may smoothly continue toward 70% vaccination rates and higher, other localities may focus on meeting lower goals.

“If we stopped and only did second doses going forward of our eligible population, we’d have 40% of them vaccinated,” said Russell of Flathead County. “We see that as a win. Now, are we going to stop at 40%? No. My next goal is 45%. Can we get to 50% at some point over the summer?” he asked. “We’re going to try.”

Alex Sakariassen contributed reporting.

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