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How Puerto Rico’s vaccine drive turned into a success

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The chief of the Puerto Rico Nationwide Guard was nonetheless coping with the aftermath of a 6.4-magnitude earthquake that displaced hundreds of residents in January 2020 when island officers started listening to studies of individuals falling in poor health from the brand new coronavirus. As soon as once more, they turned to Guard Adjutant Basic 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 crucial mission. It’s the mission of my life,” he informed 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 a better proportion 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 the complete inhabitants.

The three,500-square-mile island could seem 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 additionally by making pictures broadly 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,” stated 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 primary political divider on the island, and the 4 main events are proponents of vaccination, he stated. Irizarry thinks this may also clarify why vaccination charges are excessive in closely Democratic states, comparable 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.

José J. Reyes, adjutant normal of the Puerto Rico Nationwide Guard, helped create the island’s vaccination technique, which has gotten almost 90% of the grownup inhabitants absolutely vaccinated. Courtesy Puerto Rico 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 evening 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 can be out there. In whole, the freezers value lower than $300,000, he stated.

Puerto Rican officers developed a cheap and versatile “hub-and-spoke” mannequin for vaccine distribution, BioLife COO and president Dusty Tenney informed STAT. They created two essential “hubs” for incoming vaccines: one within the northern a part of the island and one other within the south. 4 giant freezers able to storing 300,000 doses every had been positioned at amenities with backup turbines (constant electrical energy can nonetheless be onerous to come back by post-Maria). From there, small, transportable freezers had 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 stated.

By the point the U.S. well being officers greenlit the Pfizer vaccine on Dec. 15, 2020, the island was prepared, the final stated. 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 obtained doses to inoculate well being care employees. It was the beginning of what can 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 stated a number of adopted related plans. The hub-and-spoke mannequin specifically was a solution to sort out a public well being disaster in locations with hard-to-reach corners and different logistical challenges, comparable to Veterans Affairs hospital campuses in North Carolina and sparsely populated states like South Dakota, Tenney stated.

From December to March, the Puerto Rico Division of Well being and Nationwide Guard established not 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 giant employers, such because the police and the division of training. Information 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 broadly out there, Puerto Rico’s operation was producing a excessive of almost 300,000 vaccinations per week.

A lot of the eligible inhabitants had been inoculated by late July that it was not cost-effective to take care of the big, closely staffed mass vaccination websites so the Guard shut them down, Reyes stated. 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 obtained each week. Officers administer 99% of the vaccines they obtain, stated 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 instances, the federal government issued vaccine mandates for colleges, public staff, and a few elements of the personal sector, together with eating places. That jolted Puerto Rico’s vaccination charges up previous New England’s, stated Irizarry, who has been monitoring Covid-19 in Puerto Rico as a part of a scientific coalition convened by Gov. Pedro Pierluisi.

Irizarry stated he thinks the mandates had the most important influence on vaccination charges, adopted by the provision of pictures (there are actually 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 stated.

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

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 all which remains to be excellent, Cardona stated.

“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 resolve,” she stated.

Puerto Rican officers additionally launched a strong media marketing campaign, utilizing outstanding docs, 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 non secular denominations had been additionally recruited to unfold the phrase.

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

When folks below 30 had been driving Covid-19 instances, the final met with dozens of mayors to determine how they may 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 stress-free 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 had been there to orient them and to vaccinate them,” he stated. “And we began going by way of the totally 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 finished.’”

If “getting it finished” meant Reyes strolling in full uniform with a neighborhood official alongside a seashore 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 relations, 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 follow to CPI reporters. Inequitable vaccine access was also a problem, with poorer areas lagging behind wealthier ones, a separate CPI evaluation discovered. Cardona stated she believed the info had been skewed as a result of many well being care and frontline employees resided in bigger municipalities, they usually had entry to vaccines first.

A well being care employee administers the Covid-19 vaccine to a affected person in Puerto Rico. The island’s inoculation marketing campaign included not less than a dozen mass vaccination websites opened all through Puerto Rico from January to early August 2021. Courtesy Puerto Rico Nationwide Guard

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 jap islands of Vieques and Culebra.

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

Reyes sees Puerto Rico assembly his objective 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 may fare higher throughout Covid-19 as a result of folks had been used to states of emergency attributable to pure disasters, and subsequently extra keen to comply with authorities mandates. It is smart to obey a stay-at-home order when an unlimited hurricane is en route, so folks would act the identical approach throughout an invisible disaster just like the virus, the pondering went.

What has truly performed out is “a posh situation after all, and Caribbean range makes generalizations doubly awkward,” lead writer Ian Hambleton informed 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 solely,” stated Hambleton, a professor of biostatistics on the College of the West Indies.

However Reyes thinks there may nonetheless be a kernel of reality 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 must be ready,” he stated.



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