COVID-19 Vaccinations – Where a Commitment to Diversity is Essential

In my last posting on preparedness for a post-vaccination world I touched on some of the questions facing employers in general – policy questions that should be considered now for the eventualities of later. But digging a little deeper, there are also questions to consider with respect to support for ensuring access to vaccines by communities of color. All employers have a stake in the issue of enhancing access for minorities to vaccination, but large multi-state employers, those that may be smaller/regional employers with a disproportionate share of minority employees, and of course minority owned businesses all are enhanced stakeholders. Particularly for those businesses that have supported initiatives for diversity and inclusion as a response to the issues of social justice, this is where the rubber meets the road.

Here is the issue. First of all disparities in healthcare have had an overwhelming impact on minority outcomes and causing a disproportionate impact of burden across many disease states. COVID-19 has cast a particularly harsh light on this fact where minorities in the U.S. are dying at younger agents and in greater numbers than non-minorities. Conversely, while vaccine hesitancy has been identified as a factor in the uptake of vaccines, there is a higher reserve of mistrust regarding vaccines on the part of African-Americans. With higher and harsher incidence, and higher mistrust, access to, and education about, COVID-19 vaccines is an imperative – both ethically and from a public health perspective.

However, once a COVID-19 vaccine, or multiple vaccines, are licensed and approved, distribution of the vaccines will be guided by states. The Centers for Disease Control (CDC) directed U.S. health jurisdictions to develop plans for distribution which were submitted and reviewed by the agency. A recent review of these state plans by the Kaiser Family Foundation (KFF) found the following:

  • 53 percent of the states had “at least one mention incorporating racial and/or ethnic minorities or health equity considerations in their targeting of priority populations”, meaning that nearly half do not;
  • In identifying providers for vaccinations, only one-fourth of the state plans discuss making use of providers needed to reach racial minorities;
  • Only half of the plans address communications approaches/needs for outreach to minorities or vulnerable populations;
  • Only one-third of the plans mentions the consideration for addressing vaccine misinformation, but even those that did lacked specific strategies for countering misinformation
  • In addition, states indicated that there were limitations in collecting ethnicity data on vaccinated individuals.

That there are deficits in these plans comes as no surprise given the gravity of the situation and the compressed timeframe for response. So what should businesses be considering? Given the high level of need and the considerable gaps there are some public affairs opportunities that may serve to help the situation.

  • Large employers may wish to review state plans in which they are doing business to assess the deficits that may exist with respect to their employees with particular regard to minority issues related to vaccination. A list of the state plans compiled by KFF can be found here.
  • Identify the gaps in planning and communications that might be addressed through employer-based programs:
    • Development of mechanisms to address vaccine misinformation and enhance education – or alternatively programs that curate third-party information and make it available;
    • Assess potential of public/private partnerships that might address state or regional planning and communications deficits;
  • Perform company-specific research of employee knowledge, attitudes and beliefs around vaccination to inform messaging and program development;
  • Leverage public affairs clout to pressure state health officials to address gaps in planning and communications vis a vis minorities;
  • Consider public statements of support (op-eds, paid advertising) for addressing healthcare disparities in COVID care and vaccination programs and seek and enter into coalitions with other employers.

How well we come out of this will depend on how well we manage the vaccination of enough people to actually make a difference in the course of the pandemic. Anything that falls short for any of us, falls short for all of us.

Photo by Clay Banks on Unsplash

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As the Prospect of a Vaccine Approaches, Business and Communications Challenges Are Just Around the Corner

Coincident to COVID-19 case levels in Europe and the United States entering new and serious levels comes welcome news on the development of a vaccine. Last week Pfizer and BioNTech announced findings from the first interim analysis of the Phase III studies of their candidate vaccine for COVID-19 demonstrating high efficacy levels followed this week by a similar announcement by Moderna. It was a much-craved dose of good news, spawning broad optimism during what is an extremely challenging phase of the pandemic. And while there are many questions left – from efficacy to safety to distribution – given the fact that both of these companies have stated that they will have doses ready in 2020 there appears more of a possibility that there will be more than one vaccine soon – even beginning in December.

But first there will be regulatory rites of passage. During the October 30 meeting of the CDC Advisory Committee on Immunization Practices (ACIP) which focused solely on COVID-19 vaccine development, FDA stated the prior to any approval for an Emergency Use Authorization (EUA) that the agency would reconvene the Vaccines and Related Biologics Advisory Committee tor review data submitted in support of such licensure. It would appear plausible based on the information gleaned from the data announcements that there could be a filing for an EUA very shortly which could in turn mean that limited vaccinations could start being administered very soon. Because the regulatory oversight of COVID became highly politicized, and after some missteps by FDA, some states have indicated that any federal decision will be reviewed, but that does not seem likely to present much a barrier in terms of timeline, if at all.

While vaccination may actually begin in December, the number of doses will be limited. In addition, the process of vaccination takes time. These two particular vaccines are two-dose vaccines administered weeks apart. Vaccination may start next month, but the effects will not occur until after a period following the second dose which would occur in 2021.

Nevertheless, the real prospect of a vaccine roll out raises some very practical and important questions for businesses now. This is true for business to consumer or business to business concerns – whether manufacturers or in the service sector. Vaccination for COVID-19 not only requires business planning, but communications planning in support of the decisions. Vaccination will occur in phases, with more and more people being able to access as increasing doses become available. While the initial vaccines may be utilized with very specific populations, over time there will be increasing numbers of people rolling up their sleeves. A post-vaccine world begs some specific questions:

  • First and foremost – will businesses require a vaccine of employees? And related – will businesses seek to set themselves apart by making it known that their environmental risk is being addressed with mandatory vaccination of staff? This is particularly relevant for retail establishments for example.
  • On the heels of that, will there be circumstances where access to goods and services by consumers is reliant on vaccination? This is particularly relevant for the travel and hospitality industries, but perhaps also for some medical services.
  • Related to both of these first two questions – what sort of documentation will be necessary for an individual – either employee or customer – to present evidence of inoculation? And also how will those who do not vaccinate because of medical or religious reasons be considered?
  • What are the HIPAA and privacy implications, if any, related to all of these questions?
  • What role, if any, will employers play in the facilitation of vaccinations? Currently many employers sponsor vaccines for the flu – will there be a role for COVID vaccination support? Several of the vaccine candidates are administered in two doses, several weeks apart. Will employees need assistance or support in accessing vaccines (and keeping track of which vaccine they have received), particularly if vaccinations are being required?
  • Surveys have indicated that many are reticent about taking a vaccine – will that change when vaccination moves from the theoretical to the real? Will employers have a role in educating people about the safety and efficacy of vaccines, particularly if there are circumstances where vaccinations are being required?
  • Where vaccines are required as a pre-condition to access to either employment or goods and services how will this be balanced by the fact that vaccination of the population will be a process, not an event, and that there may be many people who for one reason or another, are unable to access vaccination?
  • All of these questions may likely have different answers in different regions of the U.S. Companies that are national in scope may have to formulate responses that take into account local or regional conditions. What are the implications of uneven vaccine implementation by region and geography?
  • Finally, among the many unknowns connected with the mass production of a vaccine only developed and researched in the past few months is the long-term efficacy and safety. What is the contingency plan needed around diminishing effectiveness?

It may seem like we are a far way away from having to address these types of questions, given the fact that there is no approved vaccine yet and there are considerable distribution obstacles associated with the administration of COVID-19 vaccines to the general public. The fact that vaccination may begin as soon as December does not mean that answers to these questions are needed now. But the process for answering them is. A post-vaccine environment is going to demand business plans and external and internal communications plans that support and consider multiple scenarios and contingencies. If we have learned one thing in this pandemic, reality overtakes everything else – and the environment shifts rapidly. Public facing companies need to act now to consider strategic challenges and support responses with communications approaches that protect and preserve not only credibility, but the well-being and good will of their stakeholders.

Photo by Simon Berger on Unsplash

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FDA AdComm Agenda Covers the Bases

First of all, we are having a bit of a crisis with our crisis. As we appear to be moving into yet another wave of COVID-19 infections, and as research into a vaccine is aggressively underway, we also see serious drawbacks. Apart from the increasing numbers of cases in the United States, there has been a strong perception that the process has been politicized which in turn has brought on an increasing skepticism or crisis in confidence on the part of the public to embrace the outcome. And now, three agencies that have seen an erosion in public confidence – FDA, CDC and NIH, will participate in an FDA Advisory Committee meeting that will discuss vaccine development.

The agenda has been posted for the October 22 meeting, and the discussion will be available to view on YouTube, according to FDA Commissioner Hahn. One had to wonder what the meeting would actually be discussing since there was no candidate vaccine to consider for approval and given the fact that FDA has already issued guidance to provide a framework of understanding for how the agency will approach approval.

The order of the day includes presentations from all three stakeholder agencies – CDC, FDA and NIH and appears to be designed to add a little more meat to the bones on how each will play a role and to lay out some of the mechanics of the process. in the day they will establish a level playing field for understanding COVID-19, followed by the various key agencies explaining their part in the process, beginning with NIH, followed by BARDA with CDC discussing that agency’s role in monitoring use after either early use authorizations (EUA) or final licensure and CBER will follow up describing post-marketing surveillance systems. Another CDC presentation will discuss vaccine distribution and tracking, which is an important topic about which there are many questions, followed by a discussion on “vaccine confidence” presented by the Reagan-Udall Foundation. There will be a specific discussion of the manufacturing and control as well as the clinical considerations for EUAs and licensure. In short, broadly all the categories in which there are questions seem to represented in the agenda.

Apparently as well, they are expecting a higher degree of public participation in the Open Public Comment period, usually reserved as a 60-minute window, but which is cast for 90 minutes for Thursday. Presumably if that is the case, participation will be limited to a set number of minutes. The number of comments added to the docket that had been set up for the meeting numbered 34 as of yesterday and included two stakeholder companies engaged in clinical trials.

Hopefully what will come out of the discussion is not only the broad understanding of the background and mechanics of approval and distribution, but answers to a good number of the questions regarding the nuances of actual approval, distribution and uptake. Whatever is going to be offered up during the presentation from the Reagan-Udall Foundation about confidence, this meeting will actually be an important factor related to the confidence levels of people, particularly health care workers, in taking a vaccine once there is one to take. This meeting cannot settle for perfunctory presentations and must take the questions that were raised in the docket comments, and those that will be raised during the Open Public Comment period and respond to them in some way subsequent to the meeting. We are in unprecedented times that require unprecedented transparency, planning and sound communications that has so far been largely lacking. Meetings are often perceived as an event – but this one is the beginning of a process.

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After a Vaccine – What? The Shift from Research and Discovery to Communications

Vaccines for COVID-19 are the focus of the moment – politically and scientifically speaking. On the political front, there has not only been jockeying to try to squeeze the square peg of a vaccine development timeline into a round hole of political convenience, there is also skepticism expressed by a wary public that the process has become politicized – an unfortunate impression to be sure. Scientifically, there was the big news that a vaccine trial had experienced a serious adverse event bringing a pause to bear in its continuation, likely throwing further cold water on the political side of the equation. But eventually vaccine candidates will likely emerge as successful, developed and evaluated according to the FDA guidance laid out on the subject. What then? Who will take the vaccine and at what rate?

That question has been the subject of numerous polls which have found widely varying degrees of willingness among the public to the idea of taking a vaccine – an opinion that may be further influenced by the emergence of adverse events in the clinical trials. One poll found one-third would not take a vaccine; another found fewer than half; and one that found that only one in five would take a vaccine.

There are perhaps three major categories of vaccine outlook: (1) Those who will be early adherents and seek and get vaccinations as soon as the distribution guidelines allow for it; (2) those who will hang back and wait to see what happens but may eventually take a vaccine; and (3) those who are committed anti-vaxers who will refuse to take a vaccine under any circumstances. You do not need to expend resources on the first category and you will likely waste them expending efforts on the third category. It is those folks in the middle who are the most important to communicate with. It is their sentiments, motivators and beliefs that need to be examined.

The New England Journal of Medicine published an important Perspective piece – “When Will We Have a Vaccine? – Understanding Questions and Answers about COVID-19 Vaccination” that explored two primary parts of the question – when will there be a safe and effective vaccine and when it does become available, who will take it. With respect to the latter, the article points out that to achieve the societal aim of ending the pandemic, then uptake will have to be strong to achieve the goal of herd immunity, even when combined with the huge numbers of people who have already been infected. While noting that a range of trusted people may be utilized as trusted messengers to promote vaccination, healthcare professionals are likely to be among the most persuasive. And moreover, the article makes clear we need to think about the role of communications.

When it comes to that, some additional insight comes from a Gallup poll also published this week which looked at regard for business and industry sectors. Last year the pharmaceutical industry was ranked at the very bottom. This year there was movement and the industry is now the second-lowest regarded industry, just above the federal government, with 49 percent of respondents viewing the industry negatively and 34 percent having a positive outlook, a net negative of 15 percent. However, of note was the change in the ranking of the healthcare industry which went from the third-lowest ranking last year to somewhere in the middle with a 13-point increase to 51 percent favorability. It was the first time in the 20 year history of this Gallup poll that the healthcare industry was viewed with more positivity than negativity. It is perhaps a direct result of the extreme effort and sacrifice that has been witnessed by healthcare workers in the face of the pandemic.

Bottom line – communications planning needs to be taking place in earnest and assets should be cultivated now that will allow for credible outreach to that middle group of people who may be uncertain. The surveying of sentiment needs to be targeted and precise and consistent. The underpinnings of any campaign need to be evidence-based. Just as we can’t afford to miss the target with respect to the vaccine itself, we do not have the luxury of missing it with communications efforts around the vaccine. And the message is not only important, but so is the messenger. Looking to the rankings of the Gallup poll mentioned above, with the great advance made this year among healthcare workers and other indications that people do not want information about the pandemic coming from government officials or non-scientists, health care workers emerge as the obvious messenger. That needs to be coordinated now. Health care workers who have been on the front lines and bravely witnessed and endured the very worst this pandemic has had to offer may be the most credible. To that end, among others, medical societies should be going out of their way to finding them and to be prepared to offer communications guidance to their membership related to vaccines. Additionally, the next likely most credible source of convincing information will be the experiences of friends – friends who have been vaccinated. They will have influence both in-person and via social media. Their voices will need to be amplified. That means outlining a very cohesive, convincing and comprehensive social media strategy. Because while the main battle today is the one in science – to jump the hurdles of research and discovery, the next effort will be in convincing people to use the vaccine and that will be a communications effort. Like the science, it is best grounded in research and evidence. And like the science, the research and development of communications should be taking place now.

Photo by Markus Winkler on Unsplash

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For FDA and CDC and the Rest of Us – The Stakes Have Never Been Higher

Since last week’s posting regarding FDA credibility being on the line, there has been a swirl of activity and commentary around the evaluation of vaccine research for COVID-19 that would seem to have exacerbated the problem.

For context, last week the President issued a tweet stating that people were operating within FDA to slow progress on a vaccine without supplying any evidence, credible or otherwise, to support that. Subsequently in a speech on Thursday the President stated a pledge that there would be an approved vaccine by end of year “or even sooner” signaling urgency to the effort. But later in contradiction to that sense of urgency, the President has also re-tweeted a message that the number of deaths due to coronavirus has been greatly exaggerated – a tweet later deleted by Twitter.

More importantly, there have been new developments involving the FDA and CDC that are noteworthy.

  • First, FDA’s Commissioner appeared to walk back some of the statements made during the announcement of the Emergency Use Authorization (EUA) for convalescent plasma.
  • Second, he also apologized for the characterization.
  • Third, FDA let go of staff and a consultant reportedly involved in both the announcement and apology.
  • Fourth, FDA announced that there would be an October 22 meeting of the Vaccines and Related Biological Products Advisory Committee to discuss the developments and study around research related to a vaccine for COVID-19, without specificity to a particular company’s effort. Typically these announcements include a docket number so that the public can submit commentary into the docket, however this author found no such link in the announcement.
  • Fifth, the Centers for Disease Control issued recommendations regarding testing saying that people who were asymptomatic need not be tested, later changing it to “may be considered” – generating headlines about creating confusion.
  • Sixth, in turn, the former head of NIH expressed the sentiment in an opinion piece in the New York Times entitled “It Has Come to This: Ignore the CDC“. Just let that one sit there for a moment.

That is a lot to unpack. And those are just a few of the highlights.

There are so many moving parts, it is difficult to put it together into a coherent picture. As noted last week, the credibility of these agencies would seem to be vital to the end goal – an uptake of vaccine once one is approved. There needs to be confidence in the process and for that there needs to be confidence in the agencies involved.

Regarding the meeting of an FDA Advisory Committee, one has to ask oneself what exactly it is in the way of data that will be examined and discussed? The study subjects in vaccine trials are still getting the investigative vaccines administered to them (some require two doses – spreading out the inoculation to even greater periods of time). Subsequent to that, they have to be followed for their exposure to the virus and then assessed as to whether or not they were protected. Meanwhile, effects – both safety and efficacy will likely be sketchy at best and the effects on outliers would likely be yet non-emergent. Will people be willing to take a vaccine that has been granted authorization before the clinical trial data has been fully collected, must less examined?

In last week’s posting, I cited two surveys of people related to willingness to take a COVID vaccine. Since then, STAT published a survey that revealed that three-fourths of Americans believed the process for vaccine approval was driven by politics and not science. There may be some who say that there is a crisis of confidence in science – a high degree of skepticism, but it is far more likely that there is an even higher skepticism of politics. All that being said, the survey also found that most people would take a vaccine, even if authorized prior to the election. There were many critics of the Russian approach to approval, but the door is at least open for a very rushed process here as well.

Two questions stand out among the many that remain. First, is there actual political benefit to rushing an approval? That is not immediately clear. Will the shortcomings in managing the pandemic so far in the United States evaporate as an issue because of the early use authorization of a candidate vaccine? And second – and more importantly, what are the long-term effects of an erosion of public confidence in the gold standard set by FDA for the approval of new medicines. How will it impact confidence in future approvals – not just of these vaccines, but of all drugs? And if there is growing doubt about the integrity of FDA, will people begin to look to European regulatory authorities more readily than those in the U.S? The next few weeks will be critical in providing the answers.

Photo by Glen Carrie on Unsplash

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