Overview
As of April 2022, COVID-19 has claimed the lives of over 12,000 Mississippians, over 1,000 of whom were under 50 years of age. Mississippi has lost 13 children and 15 pregnant women, none of whom were fully vaccinated. Examined in the context of other mortality impacts, COVID-19 killed more Mississippians than all cancers did for all of 2019 and 2020 combined (8,774).
Due to a fortunate confluence of factors, the United States and international partners were able to bring effective and safe vaccines on-line in unprecedented fashion. This was due in large measure to decades of research into Adenoviral vector vaccines and mRNA vaccines. Massive investment in vaccine development was launched in a manner that put companies in a no-risk situation by funding both research and production whether a product was successful or not. To date three vaccines have been approved for use in the U.S., with numerous others abandoned during development. Additionally, the fast-track review of clinical trials by the Food and Drug Administration (FDA) and Centers for Disease Control (CDC) allowed for the expedited availability of vaccine under emergency use authorization (EUA). These processes maintained rigor of oversight and proof of efficacy, while cutting away much unnecessary bureaucracy.
Early Vaccination Efforts
Mississippi was at the peak of its most deadly surge in the winter 2020-2021 when COVID-19 vaccines first became available. Severe imbalances between supply and demand generated significant anxiety and resulted in risk-based prioritization. No group had been more impacted than those residing in long-term care settings. In the first waves of the pandemic, the majority of all deaths occurred in this group. Through a remarkable effort spanning January and February, all nursing home and long-term residents and employee were offered vaccination as a priority group, with the majority of residents being immunized. Subsequent to this, and additional efforts in long-term care settings, mortality rates plummeted and stayed low throughout the pandemic (Figure 1). Currently 86% of residents and 85% of employees in long-term care settings funded through Center for Medicaid Services (CMS) are vaccinated.
In an effort to ensure geographic parity and universal access to the highest risk individuals, Mississippi set up a COVID Centers of Excellence program. In exchange for prioritization in vaccine supply, Centers of Excellence agreed to meeting the following criteria: 1) providing vaccine to the general public, 2) outreach to underserved populations, and 3) providing monoclonal antibody treatment based on referrals from community physicians and providers. This approach served as an effective strategy to equitably allocate vaccine while promoting access to all community members.
Early in the vaccine distribution process, community health centers (CHCs) were identified as effective champions for underserved and minority communities. This valuable state asset activated all their resources to provide vaccines not only in their clinics but also in the community. Due to the highly effective way in which they reached Black and Hispanic communities, the majority of clinic directed vaccine, and a substantial proportion of total vaccine, was allocated to the CHCs. As of March 2021, 67% of all vaccine given through CHCs went to African Americans, compared to 29% for other clinic types. CHCs have demonstrated themselves to be extremely potent partners in the public health response, and now have administered a substantial portion of COVID vaccines, especially to minority communities.
Other efforts, such as the MSDH COVID Community Vaccination Partner (CCVP), paid clinical organizations to deliver vaccines through local community efforts such as church events. Any community organization could request an event, and most were accommodated within a days or weeks. In response to individual patient needs and challenges with transportation, whether homebound or other reasons, MSDH set up a hotline and email request system for at-home vaccination. CCVP partners were also funded to provide at-home vaccinations.
Drive-Thru Vaccine Clinics in Mississippi
Given the need for rapid, high throughput vaccination sites, the Mississippi State Department of Health (MSDH) and the Mississippi National Guard, with the IT and scheduling support of University of Mississippi Medical Center (UMMC), established one of the most successful endeavors of the pandemic. Over the course of several months, these MSDH/National Guard drive through clinics administered over 700,000 vaccine doses and accounted for the vast majority of doses in the first months of the vaccine response, demonstrating and efficiency and productivity rarely seen in government efforts (Image 1).
As the response evolved, vaccine became more widely available, and distribution patterns shifted to clinics and pharmacies. One of the most striking shifts has been the predominance of pharmacies as the most common location for vaccine administration. Pharmacies are the most commonly used locations to obtain COVID vaccination, accounting for 39% of all doses given, compared to 26% for medical clinics. Without a doubt, pharmacies will continue to be a growing resource for community vaccinations, even among youth.
COVID and Health Equity
Within the first weeks of the pandemic, it became clear that the most severe COVID case or mortality impacts were being seen in the African American community. With this stunning reminder of the importance of health equity for all public health efforts, MSDH and the state response incorporated sweeping changes into the operational structure, starting with the elevation of Health Equity to a command level position under the leadership of Victor Sutton, PhD. Lessons learned from the initial phases of the response helped MSDH develop effective strategies to bring vaccination to communities in greatest need. Early in the course of the vaccination effort, MSDH surveys identified greater reluctance among African Americans and Latinos to be vaccinated (Figure 2).
By addressing trust issues, reducing barriers to access, leveraging medical partnerships and relying on trusted community leaders for strategic guidance and communications, Mississippi was able to close the vaccination gap for African American and Latino residents. As of April 2022, the vaccination rate among Black Mississippians receiving at least one dose (58%) exceeds the state average (55%) and exceeds the national rate for all African Americans. Vaccination rates among Latinos in Mississippi approximate the rate among whites (50% and 51% respectively).
The benefits of these gains in immune protection are well demonstrated by the demonstrated declines in African American mortality over the course of the pandemic (Figure 3). At the beginning of the pandemic, African Americans accounted for 64% of all deaths from COVID, but over time the total percentage declined markedly to 37%, a proportion slightly below the representation of African Americans in the population overall.
Lessons Learned
The state of Mississippi, along with the country, have experienced the largest infectious disease mortality event in our history, with approximately one-million lives lost to the COVID-19 virus. Fortunately, through the dedicated efforts of scientists, physicians, healthcare providers and public health officials, many deaths and hospitalizations were averted. However, we missed great opportunities to protect a large minority of our population due to under-vaccination and failures to ensure life-saving public health measures. Misinformation, spread at the speed of social media, has served to undermine the very tools that have been proven to save lives. Looking forward to the next public health threat, we will need to learn the lessons of the past. Key to future success will be building trust in all populations, developing, and promoting unified public health messages, and leveraging partnerships with those who are able to drive immediate change.