shows a woman in red scrubs giving a COVID vaccination to a woman sitting in a chair and wearing a jaunty hat
Morgan Cash, a nurse from Vance County Schools gives a vaccination to a local resident during a mass vaccination clinic at the Granville County Convention and Expo Center in Oxford on Thursday. Photo credit: Lisa Harrison

By Liora Engel-Smith

For the first time in a long time last summer, the Madison County fairgrounds were empty. As with many other events across the state, the pandemic sidelined this annual celebration of all things agriculture.

But last month, cars carrying seniors flocked to the empty fairgrounds once again, this time not in search of blue ribbon accolades and fried food, but to get vaccinated. Cars circled the fairground rodeo arena, moving from station to station — registration, consultation with a provider, followed by a quick jab, and then, finally to a 15-minutes observation station.

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That day, roughly 15 volunteers corralled through the Asheville-based Mountain Area Health Education Center vaccinated 250 seniors in what would become the first in a series of drive-thru vaccine clinics in rural western North Carolina. On that same day, by comparison, Madison County Health Department staff vaccinated roughly 50 residents.

A county of more than 22,000 — nearly 4,700 of them seniors — Madison has many of the challenges other rural locales in the state face when it comes to vaccinating people. At almost 450 square miles of dirt roads, hollers and remote homes, finding a central location that reaches as many people as possible is a challenge.

Cars in a line at the drivethru vaccine clinic
CommWell staff organized a drive-thru vaccination clinic at a middle school in rural Brunswick County in early February. Photo credit: CommWell Health

In the initial stages of the vaccination effort, that task fell on the handful of employees at the county health department. The same employees were already inundated with answering the phones, testing residents for COVID-19 and responding to the community’s other ongoing health needs.

At just over 2,300 people vaccinated in Madison County, with roughly 200 of those getting their second dose, the effort to reach seniors is slow-going. Unlike the more populated areas in the state, where one event can reach thousands of residents the rural race to vaccinate people has come in dribs and drabs.

That is, in part, a reality of rural life. But it’s also a function of vaccine availability, said Bryan McClure, a MAHEC employee who oversees the volunteer clinic effort.

“I think supply of vaccinations is the biggest limiting factor,” he said. “Of course, if we had the vaccine, you know, we can hold these events every day.”

Drive through testing inside a room at the drive-thru vaccine clinic
To help the Madison Health Department, volunteers held a drive-thru vaccination clinic last month. It is one of a series in North Carolina mountains. Photo courtesy of MAHEC

The other piece of the puzzle, rural providers said, is finding ways to reach seniors who can’t necessarily make it to vaccine clinics for lack of transportation or because of poor health. With the highly contagious virus spreading through droplets, approaches such as busing groups of seniors to a particular location may not be wise.

The needs generated by keeping the vaccines super-cold, not to mention staffing constraints are also hampering that effort.

“You can’t be in every neighborhood on every street corner, allowing people to just be able to walk in,” said Tamara Dunn, chief operating officer at CommWell Health, a community health center that cares for thousands of residents in six rural counties out east. “We just don’t have that sort of resources.”

A phone tree 200 strong

Carl Parker got the call sometime on Tuesday. The president of the NAACP Brunswick county branch sprang into action as soon as the details were firm: CommWell Health had 200 vaccine doses. They planned on showing up at the local middle school in the community of Supply, an unincorporated crossroads that’s roughly a 10-minute drive from the beach. Supply’s 12,000 or so residents are mostly white, but roughly one in 10 residents identify as people of color.

A few people wearing masks and in the background are tents for a pop up vaccine clinic
Carl Parker, left, who heads the Brunswick County Chapter of NCAACP helped CommWell Health in a coronavirus vaccine clinic in the town of Supply. Also in the photo is CommWell employee Jennifer Bawab and David Stanley, Health and Human Services Director at Brunswick County. Photo credit: CommWell Health.

The CommWell event was a golden opportunity to make sure some residents got their first shot.

Parker got to work.

He called one member of his organization, who, in turn, called another member, and then another. The phone tree proved remarkably successful.

“We kept on linking that thing together until we had more than 200 there by the next morning,” he said.

This kind of communication, Parker said, is an important part of reaching remote residents who may not know a vaccination event is happening, particularly as the pandemic cut them off from their usual sources of information, such as the grocery store, the senior center or a church visit.

Though Parker is proud of the turnout, he knows that more people will need to get vaccinated.

“Two hundred was a small challenge,” he said. “If they needed more, we would have gotten them more.”

Dunn, the CommWell employee who helped organize the event, said these kinds of local partnerships are crucial to reaching rural residents.

“It’s something that’s brand new,” she said. “I’ve not been part of a pandemic before. And so, you can’t just pop up and all of a sudden you’re an expert at doing testing and giving vaccines.”

Staff in masks prepare syringes
CommWell staff prepare shots at a drive-thru COVID vaccination clinic in early February. Photo credit: CommWell Health.

Events like the one in Brunswick County, she added, are crucial because not everyone can drive to locations outside of their communities. Though perhaps more time-consuming than holding a mass vaccination site in a city, these events have proven to be a successful outreach approach, along with fixed vaccine clinic sites. Between these two approaches, CommWell has been able to vaccinate more than 1,000 people in its six-county region.

Outreach is slow and labor-intensive, Dunn added, and the team at CommWell gets help where they can. Support staff and CommWell’s senior management team have been helping with patient registration events, and at the Brunswick County vaccine clinic this week, staff called on the National Guard to direct traffic to the middle school.

“We serve the underserved areas,” she said. “That’s where our clinics are and we know what to do. … We are a big piece of the [vaccination] pie.”

Remote group home by remote group home

As North Carolina passes the 1.5 million vaccines mark, some residents, particularly those who are homebound, may be left behind. Paul Shackelford, a professor of obstetrics at the East Carolina University Brody School of Medicine, says he wants to narrow that access gap.

Since January, he and a team of volunteers have vaccinated eight of the most remote group homes in Pitt County. A collaboration between the Centers for Disease Control and Prevention and pharmacy companies CVS and Walgreens have been administering vaccines in some of the larger assisted living facilities, Shackelford said, but smaller providers have been left behind.

The painstaking process has led to 75 vaccinations to date, he added, with the goal of vaccinating roughly 300 of the most vulnerable residents — often poorer nursing home residents in the county.

The same approach could perhaps work for seniors who live alone and can’t go out, Shackelford said, but the approach is limited by staff and time constraints.

“If their health care is compromised by their movement, then we have a public health need to go to them,” he said. “ … But we have a substantial effort in delivering it so it’s not something we can do for everybody, but we have to learn how to do it.”

The local becomes regional

Almost 400 miles west, in Jackson County, physical access to vaccines is also a challenge, said Melissa McKnight, the county health department’s deputy health director. The health department has administered more than half of the vaccines in the county to date, reaching roughly 1,600 of the more than 3,500 vaccinations in the county, she said, out of a list of roughly 7,000 eligible residents.

Even with additional doses, the health department has been able to secure from Harris Regional and with additional vaccinating agencies in the county, that vaccination effort remains slow, since the county health department receives roughly 200 doses a week.

“We could do those giant events,” she said. “Our clinics are set up to do about 100 to 125 vaccines an hour. We calculated that in that way we could do 750 to 1,000 vaccinations a day. We’re just truly waiting for the supply.”

The vaccine effort in the county is fought on many fronts at once, McKnight said. Health department staff are getting help from the National Guard, the local emergency management system and from the department’s animal control staff.

Jackson County’s regional transit system has also joined the effort, transporting a small number of seniors who can’t otherwise make it to a vaccination site free of charge. The county’s vans and small buses are as COVID-proof as can be. Only a few passengers get on the van at a time and each of them is protected by plexiglass to minimize air droplet transmission.

But the effort of putting up a complex vaccination campaign in the middle of a pandemic is taking its toll, McKnight said.

“It is an incredibly heavy lift,” she said. “It has been a year of response now with COVID and I think the task gets bigger every day.”

Elsewhere in the mountain region, a consensus has emerged that the solution to these vaccine allocation challenges is regional, not local.

The Dogwood Health Trust, a regional nonprofit created after the recent sale of Mission Health, has convened an informal group of vaccinating agencies who not only share resources and best practices but also advocate as a collective for more vaccine allocations to the region.

“We know that every community has unique needs and challenges and we have to honor that,” said interim CEO Susan Mims. “And we know that there are efficiencies to be gained from working together. … That’s exactly what the consortium is about.”

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Liora Engel-Smith joined NC Health News in July 2019 and covers policies, programs and issues that affect rural areas. She has previously worked for the The Keene Sentinel in New Hampshire and the Muscatine...

5 replies on “In the rural race to distribute COVID vaccines, a piecemeal approach”

  1. Dear Liora Engel-Smith,
    Thank you for covering rural areas and the challenges they face. I’m including a link in this email as it illustrates how many rural counties are doing better with vaccination rates than their urban counterparts. I work in Madison County and they have had events where 300 vaccines were given in one day . This is much more than the 50 that was cited in your article. In addition Madison is achieving a 14.2% first time vaccination rate which is significantly higher than the much more urban county to the south, Buncombe, whose vaccination rate is at 10.5%.
    Here is the link that gives a breakdown of vaccination rate per county in NC.

    1. Hi Kristi,

      Thanks for reading the story. I appreciate your thoughtful comment and your work at the health department. It’s a really tough time to be in public health and if I learned anything from reporting this, it’s that you all are incredibly resourceful.

      Obviously, the 50 vaccines in that one day was a-point-in-time count for the one day according to MAHEC sources, not a tally of all the vaccines ever given by the department or even the department’s capacity. I’m sure since then the department has gotten more doses and have worked out some of the kinks of the earlier vaccine clinics, so things got faster.

      It would have been preferable to get that information directly from the health department, and I tried to reach the health department several times via email and phone over the course of two weeks, but unfortunately was unsuccessful in my efforts. I’m sure the reason for that is because you guys are incredibly busy with this vaccine campaign and coronavirus response. In the absence of direct information from the department, I had to go with the information I got from the agency that’s been collaborating with the health department, in this case MAHEC.

      The pandemic response is changing rapidly and this story is now probably outdated when it comes to vaccination rate. But it is important to note that the tally on NCDHHS’ website includes all the agencies that are also giving vaccines in Madison County. That can include community health centers, hospitals and agencies like MAHEC.

      Because vaccines are not offered universally at the moment, what matters is not the vaccination rate as a function of the total population, but how many eligible folks are getting their vaccines. Counties like Madison tend to have a lot of older people, meaning that the pool of eligible folks is likely large compared to the doses the county is allotted per week. It’s messy and complicated as I’m sure you know first hand.

  2. I wanted to add a comment to my earlier message. Madison County vaccinated 650 people today. That is an impressive amount for a population of 21,755.

  3. Thank you for taking the time to cover some of the difficulties of getting people vaccinated in the rural setting. You are correct about the large geographic area and transportation difficulties that many face. In addition the older population tends to be a bigger percentage of the population. I appreciate your disclosure on your sources for the article as well. I am sorry you were unable to directly interview with someone in Madison County.
    Currently the county health department has teamed up with Hot Springs Health Program so that all the vaccine is being managed through the health department. Earlier the two long term care facilities did vaccinate their staff and residents through their own supply chain. The health department is triaging the waiting list so the most vulnerable are vaccinated first.
    Registration can be done by phone as well as through Hot Springs Health Department if they are a patient there. Because of the teamwork in Madison County people are able to register more easily and do not have to be computer savvy to get a vaccine. Our effort to reach seniors is not slow going.
    We would love to have a larger supply of vaccine and that has been an issue as it has been for many counties. However the vaccine received is quickly used for those most vulnerable. Mass vaccination days have successfully vaccinated 550 people in one day thanks to the excellent organizational skills and hard work of many people working together. Often the media has a bias towards urban counties and struggle to portray rural areas accurately even though they can be just as successful and resourceful. The vaccine dashboard link has many examples of this.
    Thank you for your time and conversation.

    1. That is awesome news! I have your email, so I’m going to email you. I’m always interested in learning about innovative programs in the rural space. Please consider letting me know about the good work you guys do.


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