CROSS LANES, W.Va. — Karen Meadows’ plans on Wednesday did not involve leaving her house, and they certainly did not involve a Covid-19 vaccination. Wired to an oxygen tank and largely homebound with chronic obstructive pulmonary disease, it’s a challenge for Meadows to make it up her driveway. The voyage to her county’s mass vaccination site, at a basketball arena 10 miles to the east, is all but impossible.
But then came a stroke of luck. Down the block, a local doctor was administering a vaccine to her mother-in-law, who is homebound herself. She called Meadows, who, clad in a pink bathrobe, welcomed the doctor into her living room. Fifteen minutes later, she was sporting a smile and a Band-Aid.
For Meadows, it was a life-changing encounter. She had largely given up on receiving the shot — not for lack of interest, but for the simple logistical reasons that could keep hundreds of thousands, if not millions, of highly vulnerable, homebound Americans from getting vaccinated.
“I could not stand in line and go to the Civic Center,” Meadows told Sherri Young, the county’s top health official, as she administered the single-dose Johnson & Johnson shot. “The waiting in line, the parking — there’s no way I could have done it.”
Grateful as Meadows was for the house call, the time and energy it required highlights a bleak reality. Homebound individuals, who are among the country’s most at-risk, have little chance of receiving a vaccine if not for the heroism from individual health workers, and their choice to spend precious hours making painstaking, door-to-door treks to administer doses one at a time. Young’s journey to deliver barely a dozen vaccines required a day of driving and hours of planning beforehand, too, to gather names from local senior services organizations and to chart the most efficient route from house to house on Google Maps.
That effort also underscores just how far other counties and states have to go. While most homebound Americans have been vaccine-eligible for months, many have been forgotten by a system that prioritized mass vaccination sites and assisted living facilities. More than three months into the U.S. vaccination campaign, there is still no national plan to vaccinate those confined to their home by illness, frailty, or disability. In most cases, the infrastructure for reaching them consists of little more than a doctor, a car, and a cooler.
For Young, however, the benefits far outweigh the costs. In a single 20-minute span, she immunized not only Meadows and her son, but also her 84-year-old mother-in-law, Anna Hull, and her 83-year-old husband, Billy. All four knew they wouldn’t have been vaccinated anytime soon if not for the doctor’s visit, and none was shy about communicating their thanks.
“I’ve seen you on TV,” Meadows told Young before she left. “What you do, it’s a wonderful thing. You work your butt off.”
While the country’s early vaccine campaign has outwardly focused on the most vulnerable, in practice, it has skipped over many of the oldest and sickest Americans. While over two-thirds of America’s seniors have received at least one vaccine dose, the rest won’t be nearly as easy to reach.
Roughly 2 million people in the U.S. are either partially or fully homebound, recent studies estimate. Many are elderly, and those younger than 65 typically have a severe illness or disability. In effect, any homebound American, and each of the West Virginians who Young visited last week, has been eligible for a shot since January. But being eligible and being vaccinated are sometimes unrelated concepts.
It’s no surprise that the vaccination effort is missing homebound people, experts say. The federal government and local health departments are facing immense public pressure to boost vaccination rates. As a result, their effort to stamp out Covid-19 has led them to largely focus on a single metric: total doses given.
“The only thing people are really measuring or paying attention to is how many vaccines are being administered,” said Marcus Plescia, a North Carolina-based doctor and chief medical officer for the Association of State and Territorial Health Officials. “That doesn’t really provide opportunity, or an environment, where states and local governments can afford to put a lot of emphasis on populations like the homebound.”
After a recent increase in supply, however, many states have devoted new resources to vaccinating those hardest to reach.
Last week, Texas began deploying National Guard troops to administer vaccines to homebound older adults. Earlier this month, Florida began assembling “strike teams” that reached 1,500 homebound older adults in the program’s first weeks, and has since launched a dedicated email service for others to request a house call.
Cities have also organized their own efforts. Health officials in St. Louis, Mo., launched a homebound vaccination service on Thursday. New York City announced a similar program and dedicated website last week, and aims to vaccinate its entire homebound population by the end of April.
The timing, however, illustrates just how far behind many of America’s most vulnerable older adults are. The end of April will mark nearly four months since most Americans 65 and over first became eligible for a vaccine.
“It’s a work in progress, at best,” said Ruth Katz, the senior vice president for policy at LeadingAge, an advocacy group that represents thousands of nonprofit aging services providers. “There’s still a lot of frustration out there.”
When it comes to vaccinating homebound individuals, the success in West Virginia’s Kanawha County is exceptional. But the labor required for the campaign here only illustrates how difficult it will be to execute similar campaigns across the country.
To begin with, a targeted homebound vaccination campaign requires planning and good fortune. Young, who served previously as West Virginia’s first-ever immunizations czar, began charting out this county’s vaccination campaign months before any vaccine received approval for emergency use. Thanks to a highly successful rollout, Young said, she’s more credible than ever with the West Virginia National Guard officials helping to determine vaccine allocation.
As a result, Kanawha County was the first in the state to receive an initial supply of one-dose Johnson & Johnson vaccines, which the Food and Drug Administration authorized on an emergency basis in early February.
“I’m not afraid to beg for a vaccine,” she said. “Every vaccine we get, we get it all in arms within a week.”
The doses are being put to good use. During a brief span on Wednesday, Young visited an 86-year-old who, without the use of his legs, rarely left the hospital bed in his living room. A later stop brought her to a 70-year-old mostly confined to her bed with Parkinson’s disease, whose daughter had considered but decided against making the long drive to Charleston, the state capital.
Machine, not man, had kept a wheelchair user effectively trapped in his home for weeks: The hydraulic lift he used to skip over his front steps was broken. The maintenance company hadn’t returned his calls.
In every case, they made clear to Young that were it not for her efforts, they never would have been vaccinated.
Beyond the vaccines and syringes, the homebound vaccination process didn’t require much equipment beyond transportation — in this case, an undercover, cobalt-gray Dodge Durango courtesy of the county sheriff. It doesn’t cost much, either. The federal government provides vaccines to states, and in turn to cities and counties, at no cost.
Vaccinating homebound people in large numbers, however, is dramatically more complicated and time-consuming than the dollar cost suggests.
On Wednesday, Young, the county health executive, spent seven hours traveling from house to house in a car driven by Capt. Jeff Meadows of the Kanawha County Sheriff’s Department. The day before, Meadows (no relation to Karen) had made roughly 15 calls to those who had requested a vaccine visit, establishing a preliminary schedule for his and Young’s trip. He later spent an hour on Google Maps charting the most efficient routes between roughly a dozen homes in Charleston and its suburbs, some of which were separated by nearly 40 miles.
Young and Meadows, who have worked together on the county’s pandemic response since May, have turned their recent home visits into a routine. Throughout the day, Young took brief medical histories, drew vaccine doses from vials, administered the shots, applied bandages, and monitored patients for allergic reactions for roughly 10 minutes afterward. Often, she also offered vaccines to family members and caregivers, who, regardless of their age or health status, represent homebound individuals’ main connection to the world outside their doors, and therefore their biggest risk of contracting Covid-19.
Meadows did the driving, and plenty more. After pulling into a new driveway and making another phone call to announce the team’s arrival, he’d lug the vaccine cooler and a first-aid kit indoors, fill out CDC-branded yellow cards that show proof of immunization, and use an iPad to enter patient data into the Center for Disease Control and Prevention’s nationwide vaccination database.
Young, too, had spent hours planning. In recent weeks, she has scrambled to reverse-engineer a list of homebound patients in her county. To help, she enlisted local nonprofits, including Paralyzed Veterans of America and Kanawha Valley Senior Services, to spread the word. Local emergency services companies helped, too, by giving a heads-up to the many locals with kidney failure who require an ambulance ride to reach their dialysis clinic.
The current wait list of people who’ve requested at-home vaccination numbers around 200, Young said. While she’s still adding names almost every day, the list is shrinking faster than it’s growing, thanks to her weekly house calls and those of other local health workers.
For Young, the work is personal. Growing up, she recalled, her late grandfather was fully homebound, paralyzed due to a spinal injury that occurred during a long-ago cancer treatment. She didn’t need extra inspiration to help those confined to their homes in her county today, she said. Still, though, memories of her grandmother’s daily slog to turn, bathe, and feed him have only magnified the urgency of her recent work.
“Yesterday was Zoom after Zoom after Zoom,” Young said. “This is a heck of a lot more gratifying.”
In most cases, vaccinating homebound people would be impossible if not for the February authorization of Johnson & Johnson’s single-dose Covid-19 vaccine.
Unlike the two-dose vaccines developed by Moderna and, especially, the Pfizer-BioNTech partnership, the shot is easy to store. Early in the state’s vaccine rollout, the difficulties of transporting the ultra-cold Pfizer vaccine made giving shots anywhere besides a clinic impractical.
Johnson & Johnson’s vaccine, Young said, is a “game-changer.” Beyond its relatively lax storage requirements, the fact that it requires only one dose means it takes half the labor to administer. The detailed logistical effort needed to schedule second vaccine appointments at specific intervals, she said, was also a deal-breaker.
“I love having the J&J for home visits,” Young said. “Otherwise you’d have to wait 21 days for [a second dose of] Pfizer, 28 for Moderna.”
Without exception, every person Young immunized was thrilled to be receiving the Johnson & Johnson shot. Their reasons varied, but many expressed concern about the side effects reported by those who received Pfizer or Moderna doses. Among them was Pamela Doss, 61, Young’s first visit of the day.
“They way everybody talked when they had two vaccines — the second one made them sicker,” Doss said.
Young warned, however, that the Johnson & Johnson jab can have side effects, too. She departed each house with a reminder to stay hydrated and to treat potential chills or headache with over-the-counter painkillers.
She also used concerns about new variants of the SARS-CoV-2 virus as a selling point.
“You know those variants you see on the news?” Young asked Doss. “This is one of the best ones against those variants.” (Some data shows the Johnson & Johnson vaccine is highly effective at protecting against severe disease and death regardless of viral strain, though it’s hard to directly compare them.)
Easily the best perk, however, was the sheer convenience of a single-shot vaccine.
“Do I have to have two of these?” one man asked, just as Young prepared to leave.
Young’s reply became a refrain that she and Meadows, the sheriff’s deputy, used throughout the day: “One and done.”
Vaccinating homebound individuals doesn’t just depend on heroism from health workers. Even in Kanawha County, the people seeking vaccines must work just as hard to secure a dose, often with limited success. Those who did succeed, however, said they would have kept trying as long as they needed to.
Doss, Young’s first visit of the day, said she had been trying to schedule an at-home vaccination appointment since January.
“You don’t know how long I’ve been waiting for this shot,” she told Young as she entered.
But her phone calls, she said, were well worth it once she secured a vaccine appointment — and once she told her friends and family it wouldn’t require an impossible trip downtown. The most frequent reaction, as she recalled, was disbelief: “You mean they’re coming to your door?”