UCSF Grand Rounds: Status updates and addressing vaccine hesitancy, passports and incentives

In another sign of normalcy in the Bay Area and United States, UCSF Grand Rounds moderator Dr. Bob Wachter started today’s session by notifying viewers that, following the next Covid-19-themed Grand Rounds, the speaker series will take a break, thanks to diminishing covid numbers and the “amazing success” of the vaccine rollout. 

Following an overview of those numbers by UCSF epidemiology and biostatistics professor Dr. George Rutherford, three experts presented on vaccine passports, incentives, and efforts to vaccinate San Francisco’s Latinx population with Unidos en Salud. 

Covid numbers

“We’re clearly through this third wave of the epidemic, which only touched the United States very lightly,” Rutherford said. There were 3.5 million new cases worldwide last week, a 15 percent drop compared to the week before, and 78,000 new deaths, a 7 percent drop. Cases are falling in India and Europe, Rutherford said, though not in South America.

Nationally, there is an average of 16,000 cases daily (a 46 percent drop in the last 14 days) and almost all states and territories are experiencing declining case rates, except for the Virgin Islands and Arizona. California is tied for the lowest case rate per 100,000 people with fewer than 1,000 cases daily and an all-time high ICU capacity since the pandemic’s start. (The New York Times puts the Northern Mariana Islands ahead.)

Exactly 43.8 percent of California’s population is fully vaccinated, and 54.5 percent have at least one dose. Though “we’ve done a really good job in the Bay Area of getting people vaccinated,” Rutherford said there is an urban-rural divide in the state’s vaccination rates. In Lassen county in Northern California, only 19.5 percent of the population is fully vaccinated, compared to 60.3 percent in San Francisco.

The proportion of those who are fully vaccinated has risen to 62 percent nationally, Rutherford said. He primed the pump by mentioning Anheuser-Busch’s incentive to give every American over 21 a beer if the country hits President Biden’s 70-percent vaccination goal by July 4. 

He also mentioned other incentives, including California’s vaccine lottery, which is offering 10 prizes of $1.5 million and 30 prizes of $50,000. California will spend $116.5 million in incentives, which Rutherford said is fairly weighty, but “less than less than the cost of having another outbreak.” He noted that vaccinations have gone up nationally following the CDC’s change to masking guidelines, but said, “who knows whether it’s cause and effect.” 

Vaccine mandates and passports

Reflecting on early expectations surrounding vaccine mandates, Dr. David Studdert, Stanford University law and medicine professor, said, “One thing that was fairly clear from the outset is that there wouldn’t be a government mandate.”

Outside of childhood vaccine laws, he said, there “really isn’t much precedent in U.S. public health policy for [vaccine] rules,” and most experts are opposed to, or at least “quite skeptical about,” mandates. 

One central concern is that mandates may cement hesitancy for reasons explored below. Meanwhile, voluntary programs can improve uptake “if they’re buttressed by efforts to increase access, to reduce mistrust” and to use alternative incentives, Studdert said. 

Studdert, with a few exceptions, was correct in his March predictions that federal and state governments were highly unlikely to take the lead in vaccination verification programs. One exception is Santa Clara County, where employers are required to ask employees about their vaccination status, and those who choose not to disclose or are not vaccinated will be required to submit to a testing regime or other rules when returning to work. 

What he did not expect was that some states would introduce legislation to ban vaccine verification in the private sector, which he noted is “breaking strongly on political lines.” 

Studdert was also incorrect in his guess that the private sector would lead the way in implementing vaccine passports, which, he said, has been “modest.” Even in New York state, where people can apply for a unique QR code that verifies they are vaccinated, only 10 percent of vaccinated New Yorkers have applied, and “most private businesses have not paid attention to them.” 

Why? Studdert thinks the blurring between private venues requiring individuals to show proof of vaccination and government-imposed vaccine mandates scares the private sector, contributing to mostly unfounded legal fears regarding proposals. He also highlighted backlash from vocal groups and a general lack of a constituency for such policies.

Incentives

While there isn’t a large push for vaccine passports, there is certainly a constituency for incentives. Dr. Kevin Volpp, University of Pennsylvania’s director of the Center for Health Incentives and Behavioral Economics, and the world’s leading expert on behavioral economics and health care, according to Wachter, noted that the multi-million dollar lottery prizes being offered in five states are all “unprecedented.” 

“It used to be a big deal for an incentive for health behavior to be $1,500,” he said. Though there are a number of good reasons to consider incentives, Volpp is concerned that “this may not be the best path for us as a country to be going on.” 

Potential concerns include equity issues for those who are already vaccinated and may not be eligible for new incentives, the idea that incentives may send the message that vaccines are unsafe, and the possibility that we are “creating a monster,” in the event that boosters are required. 

Volpp believes there are better alternatives than wide-scale financial incentives, including more selective mandates (such as requirements for vaccinations in schools or in colleges), conditional incentives for traveling or going to music venues, or raising health insurance premiums for unvaccinated individuals. 

However, given the resistance to mandates and conditional incentives across the country, Volpp believes that a lottery is the best choice among financial incentives, because large rewards are eye-catching, can engender anticipated regret for those who may not otherwise get vaccinated, and generate free vaccine advertising in the form of human interest stories. 

Latinx uptake

Unidos en Salud, an alliance between the Latino Task Force, UCSF researchers and increasingly SF Department of Public Health, focused on optimizing and innovating community-based covid test and vaccination responses to address inequalities, UCSF assistant professor of medicine Carina Marquez said. 

In January, the group surveyed 4,133 people who got tested at their vaccine site, and found that vaccine confidence among Latinx participants was high, with 86 percent of people saying they would definitely or probably get it. 

This led the group to focus on access and trust as a part of their multi-component community-based strategy, “Motivate, Vaccinate, Activate.” Community mobilization and demand generation were key focuses, as well as accessible vaccination sites and low barriers with language and scheduling. Trusted messengers were also a key component. 

“We wanted to leverage the social networks of people getting vaccinated, to increase uptake,” Marquez said, noting that, in addition to a community health team, the site also encouraged people to become vaccine ambassadors with friends and families. 

Between February 1 and May 19, the group administered close to 21,000 vaccines, with 81 percent going to people of color and 71 percent specifically to Latinx individuals. 61 percent of recipients had an annual income below $50,000, and only 46 percent had a primary care doctor. 

The site was effective in getting individuals vaccinated sooner, as 58 percent of participants in May thought they would have received the vaccine later, and 90 percent reached out to one or more people about being vaccinated. 

What is the secret sauce? Trust and convenience, Marquez said. Though vaccine rollout is not one-size-fits-all, demand generation, adaptable mobilization, and convenience all helped with uptake.

See our previous Grand Rounds coverage here.