How can we make sure people get the second COVID-19 vaccine dose?

Note: This story was originally published on December 13, just before the start of vaccination for frontline health care workers. It has been updated as of January 8 to reflect policy announcements related to the release of vaccine that has been held in federal reserves.

Despite the sense of optimism generated by the availability of highly effective coronavirus vaccines, the pace of initial distribution and a surge in case numbers has led President-elect Joseph Biden to recommend the release of nearly all available doses after he takes office. This differs from the Trump administration's strategy of reserving nearly half of U.S. vaccine production to ensure second doses are administered to those who have received an initial dose.

While releasing all available vaccine could speed up the number of people receiving a first dose, all experts agree that a second dose is necessary to achieve full and lasting protection against severe COVID-19.  

The uncertainty around the effectiveness of a single COVID-19 vaccine dose and the potential for increased intervals between the first and second doses makes Mark Fendrick, M.D., anxious. Especially, he says, if the new distribution strategy will delay some people from receiving the second vaccine dose on the schedule recommended by the U.S. Food and Drug Administration, which is 21 days for the Pfizer-BioNTech vaccinee, and 28 days for the Moderna vaccine. 

For decades, Fendrick, a University of Michigan primary care physician and researcher, has studied what it takes to make sure that Americans get the essential preventive services that can help them stay healthy. 

So what’s his worry? 

“There are several factors and behaviors that prevent many well-intentioned people from completing a two-step process, like that recommended for the COVID-19 vaccines,” he says. “We need to provide everything necessary to support those who receive the first shot to make sure they complete their second dose.”   

This lack of completion has been well established for other two-dose vaccines, like those that prevent less contagious and less lethal conditions, such as shingles, human papilloma virus (HPV), and hepatitis B. Fendrick worked on studies of the latter vaccine early in his career. 

“On the positive side, out-of-pocket costs – one of the most significant barriers for vaccine uptake --  has been removed for COVID-19 vaccines, thanks to federal action,” says Fendrick, a general internist at Michigan Medicine and director of the Center for Value-Based Insurance Design, which has fostered research and policy initiatives to enhance access to preventive care. 

“But vaccines that require more than one dose create additional behavioral and environmental challenges, including reports of side effects, false claims regarding vaccine safety, logistical barriers, and the politicization of the program, that may deter people from getting vaccinated or returning for their second dose,” he says. “Studies of other high-value vaccines and medications to manage chronic conditions show that even when provided at no cost, patients take them half the time.”

What might help?

Vaccination kits include a card that is given to each person receiving their first dose, to document vaccine information and encourage the pre-scheduling of second-dose appointments.

While useful, Fendrick has advocated that a smartphone-based vaccine adherence support program, built on research by his team and others, be added to optimize vaccine uptake. 

“These card I received after my first dose of the vaccine was very similar to the ones handed out 50 years ago. We have the technology,” he points out. “Smartphone apps and wearables already succeed in getting people to take their medicine, check their blood pressure or blood sugar, or even measure their heart rhythm.”

Beyond automated reminders, a quick call or email from someone at a trusted source could do wonders, he says. 

“Just knowing that someone cares and is willing to reach out has worked wonders in getting more people engaged in their health care behaviors,” says Fendrick. “This is particularly true for under-served groups that are at the greatest risk from COVID-19, like the elderly, and those with low incomes and without stable housing.” 

The tailored messaging elements of a COVID-19 vaccine support program would include:

•    Education about how the vaccine works 
•    Information about vaccine side effects and their treatment
•    Scheduling and reminders of second dose appointment  
•    Updates and easily understandable and accessible information to dispel misinformation and rumors that could give someone doubts about getting a second dose
•    Transportation options to second dose appointment

This last one is especially crucial, Fendrick notes. Lack of access to transportation has stood in the way of other preventive health services. Making sure that people know where to turn if they need help to get to their second-dose appointment, and making it possible for them to get the second dose at a convenient location, will be critical.

“Given the enormous stakes, we should aim for the same high level of customer service used the most effective online retailers, where they regularly check in after you visit their site and buy something,” Fendrick says. “They know what works to make consumers feel appreciated. This same personalized approach should be used to let each person who needs to return for a second vaccine dose feel like the most important person in the world – which, in my opinion, they are.”

What about cash incentives?

In addition to customized messaging, Fendrick feels that small financial rewards like a $50 gift card would further increase vaccine uptake. 

While some experts have suggested paying people to get the first vaccine dose, Fendrick lands on the side of enrolling people in a no cost adherence support program after they receive their first dose, but paying the financial reward after they complete the 2-dose regimen.

“We need to focus the rewards for those who have made the effort to get both doses and for fulfilling their broader societal role in reducing the disease’s impact.” 

What can providers and employers do?

Having surmounted incredible hurdles to develop, test, produce and distribute the vaccines, hospitals, clinics, pharmacies and state and local health agencies are making a similarly massive push to get the vaccine to everyone who can take it.  

Employers, who have a big stake in the ability of their employees to avoid COVID-19 and safely return to work, may also want to consider offering support programs that include monetary incentives or other perks such as a charitable donation to encourage full vaccination. 

Whether or not the vaccine is mandated, this would reward employees for reducing the spread of the virus and contributing to the opening of the economy.

Those who administer the vaccine also play a key role to make sure people complete the two-shot regimen. 

“The good news is that the federal government has put in place a financial incentive for those who dispense the vaccine by paying a higher reimbursement rate for the second dose than for the first,” Fendrick says. “Why not also give incentives to patients?”

Fendrick has long supported the idea of aligning patient- and provider-focused tactics to increase use of essential medical care.  

Published research has shown that when both patient and provider are given incentives to complete a specific behavior, like taking medicines to lower cholesterol, the impact is greater than the individual parts. He is quite confident that alignment of incentives will result in higher vaccine uptake.

“We can’t let the last leg of the remarkable COVID-19 vaccine journey – the second-dose problem – stop us from completing this quest to end the worst pandemic in modern history,” Fendrick says. “We’ve gone 98 yards down the field in record time. We have to do everything possible get over the goal line, so we can all get our lives back.”