Vaccine Mega-site Business Model in Peril

Vaccine Eligibility Expansion Leads to Big Changes in Volunteer Incentives & Participation

The “state-organized” mega-sites that have become the flagship of the ADHS’ vaccination brand are built upon a foundation of volunteer labor.  A primary incentive to recruit volunteers for the sites has been the thank-you vaccine at the end of a shift. Of course, not everybody has been volunteering for a vaccine- but a significant portion of volunteers are.

Last week I warned that opening vaccine eligibility to all adults would undermine the incentive to volunteer and therefore the business model under which these “state managed” mega-sites operate. The reason is simple. Any adult now qualifies for a vaccine and can now make an appointment at a pharmacy, community health center, county vaccination site or even one of the “state run” mega-sites. They no longer need to volunteer to get a shot.

This week it became clear that the lack of volunteers has resulted in poor throughput at the flagship State Farm mega-site, causing long lines and unacceptable wait times.

I’m not arguing that opening eligibility to all adults was foolish. What I am saying is that it’s foolish not to anticipate how your decisions in one area of the response impact other areas. In this case, how opening eligibility to all adults changes the incentive to volunteer – and what impacts that will have on a business model that RELIES on volunteers.

Effective leaders anticipate what impact their decisions will have and implement plans to overcome response shortcomings. For example, before making all adults eligible, the ADHS should have activated a contract to supplement volunteers with paid staff to the sites using their CDC funding or even money that the Governor has at his disposal through the American Rescue Act.  Alternatively, members of the Arizona National Guard could have been scheduled in anticipation of the need to supplement labor needs.

Other solutions could have included shifting the vaccination business model to a more distributed one- with more vaccine going to pharmacies, community health centers, county run PODs and primary care doctor’s offices. Even simply booking fewer appointments per hour would have made a difference.

Over the last week or so, 2 to 3+ hour waits have become commonplace at the flagship State Farm mega-site, making it clear that the state leadership team didn’t anticipate the impact that opening eligibility would have on the incentive to volunteer. Or, if they did, the didn’t implement plans to overcome the challenges that they knew might occur.

Now that there’s increasing media attention on the unacceptable wait times at their flagship site, I expect that they’ll make some decisions to at least make the optics look better, like reducing the number of appointments per hour at their branded mega-sites, or maybe even implementing staffing contingency plans.

One thing is for sure- they’ve invested too much in their State Farm site brand to let it sour.

5pm Update: After denying all day yesterday and today that a lack of volunteer labor was at the heart of the unacceptable delays of the last week, Governor Ducey and Director Christ announced a host of interventions:

  • Using Arizona National Guard troops at their sites (90 per day)

  • Switching to a paid model for their branded mega-sites

  • Adding 30 paid staff per shift

  • Reducing volunteer shifts to 6 hours

They’re still not conceding that the lack of volunteers (and their failure to anticipate that shortage) is the reason why there have been huge wait time over the last week However, all the above interventions are about staffing, so it’s a tacit admission I guess.

At least they’re fixing it now that the media covered the story.

ADHS Expands Vaccine Eligibility to All Adults

Decision Jeopardizing Business Model for the Vaccine Mega-Sites

Given how chaotic last week was, it might seem like the decision to open up vaccine eligibility to all adults happened a few weeks ago- but it was just a week ago tomorrow.

It looks like what happened is that the ADHS observed that the demand for vaccinations in the 55+ year-old group had waned quickly. Ever since December, any appointments that had been released by the state were snapped up in a matter of minutes (which presented big problems for underserved communities, but I digress).

But over last weekend, appointments just sat there on the ADHS website – suggesting that demand among the eligible groups has waned quickly. Their response was to open up eligibility to all adults, an announcement that was made on Monday.

The county health departments are accustomed to finding out about policy changes on the Governor’s twitter account or in an ADHS media release…  but in this case some of the county health directors got a text 9 minutes before the policy change was announced, so that’s an improvement.

There’s some merit to going to an age-based system… but the problem is that Director Christ made no accommodation for persons with intellectual and developmental disabilities before this policy change – and now folks in that category need to compete with four million other adults for those appointments (see our blog from last week). At least they qualify for a vaccine now.

Note: By expanding eligibility to all adults this quickly, the ADHS is jeopardizing the business model for the vaccination centers. Vaccine PODs (including the ones organized by the state) rely on volunteer labor.

One of the key motivations to volunteer is that one gets a vaccine at the end of the shift. Now that all adults qualify, I expect to see fewer persons to self-present as volunteers because now they can simply make an appointment without volunteering.

Extending Preventative Oral Health Coverage to Pregnant Medicaid Members Would Save Money & Improve Birth Outcomes

Good oral health is more than just a nice smile. Having good oral health improves a person’s ability to speak, smile, smell, taste, touch, chew and eat. Untreated tooth decay leads to needless pain and suffering; difficulty in speaking, chewing, and swallowing; and missed school days. Evidence also suggests that poor oral hygiene and health increases the risk of other health problems like diabetes, stroke, heart disease and bad pregnancy outcomes. 

Physical and nutritional changes that occur during pregnancy often lead to an increased risk of dental and gum problems from increased inflammatory response, loosened ligaments and increased acidity in the mouth. In addition, several studies have found a link between gum infection and poor birth outcomes, such as pre-term deliveries, lower birth weight and high blood pressure, which can lead to serious complications for both mom and the baby.

Many studies have found a relationship between periodontal disease and worse birth outcomes- but until now there hasn’t been a systematic overview of systematic reviews.  Now there is.  This new systematic overview found a clear relationship between periodontal disease and pre-term birth, low birth weight and preeclampsia (potentially dangerous high blood pressure during delivery).  The researchers reviewed 23 systematic reviews (including between 3 and 45 studies) and found an association between periodontal disease and preterm birth (relative risk, 1.6), low birth weight (LBW; relative risk, 1.7), preeclampsia (odds ratio, 2.2), and preterm low birth weight (relative risk 3.4).

The implications of the study are profound.  The estimated population-attributable fractions for periodontal disease has a mid-point of 16%, 18% for low birth weight, and 22% for preeclampsia.  Let’s look at what that means here in AZ.

In 2015, 7.2% of AZ live births were low birthweight (less than 2.5 kg).  With about 80,000 births (5,760 low birthweight births a year), that means periodontal disease is potentially contributing to 1,036 low birthweight weight babies each year in AZ. 

About half of AZ births are paid for by our Medicaid program- meaning periodontal disease may be contributing to 520 low birth weight babies among Medicaid members every year.  Let’s look at what that might be costing.

An analysis by Truven Health Analytics a few years ago found that the average health care cost for a low birth weight baby during the first year of life is $55,393 compared with $5,085 for a non-low birth weight baby. 

Putting the two estimates together suggests that the 520 pre-term babies potentially attributable to periodontal disease (and paid for by Medicaid) would cost about $29M for the first year of life compared with only $2.6M for a similar number of non pre-term births, a savings to the state that is much greater than the realistic estimated maximum cost of the benefit of $470,000 , which is orders of magnitude less than the estimated cost savings.

Sadly, the legislature’s budget committee has created a convoluted theory that grossly overestimates the cost of this benefit (which is stopping many legislators from supporting the measure). They theorize that a whole bunch of women will present earlier in their pregnancy than they otherwise would have because their dentist (not their doctor) will discover the pregnancy, tell the woman’s health plan about the pregnancy, and then the health plan will move the woman to the SOBRA Medicaid category (which has lower reimbursement). Using this ridiculous theory- they estimate the benefit to cost $4.1M.

This is of course a preposterous estimate. Even if were true in a few cases, it would actually be a good thing, because the woman would learn of her pregnancy earlier and begin getting prenatal care!

You can’t make this stuff up, folks.

The state legislature is in the middle of budget negotiations and Rep. Kelli Butler is again leading the charge to get this cost saving intervention in place. Let’s hope the evidence and return on investment will finally win the day.

PS: Here’s a terrific article by Rebekah Sanders at the Arizona Republic entitled “The Arizona Legislature cut costs. It left low-income pregnant moms without dental care.” which makes the compelling human case.

Dr Gerald’s Weekly Epi & Hospital Report

Dr Gerald’s Weekly Epi & Hospital Report

This week saw a 10th week of meaningful declines in Covid-19 cases and hospital occupancy. Absolute levels of SARS-CoV-2 viral transmission are below 50 new cases per 100,000 residents per week threshold in many Arizona counties.

As of March 21st, new cases were being diagnosed at a rate of 53 cases per 100,000 residents per week. This rate is declining by 8 cases per 100,000 residents per week.

The test positivity rate for traditional PCR testing is now <10% which is within the recommended 5 – 10% range for optimal public health practice.

In all communities, absolute levels of transmission and test positivity have reached levels that warrant a return to in-person instruction using a hybrid mode or reduced attendance.

Hospital Covid-19 occupancy continues to decline in the ward and ICU. Access to care however, remains somewhat restricted as the backlog of medically necessary non-Covid procedures is addressed.

Arizona is still reporting a large number of weekly deaths and this count may underestimate true fatalities. The week ending January 17th will be Arizona’s deadliest with >1000 deaths.

According to the CDC, 20.4% of Arizona adults have received at least 2-doses of vaccine while another 14.5% have received 1-dose. The ADHS Dashboard is reporting slightly higher levels. 

Will’s Editorial Note: Governor Ducey and Director Christ are Arizona are now conducting a natural experiment with the people of Arizona as all required mitigation measures have now been eliminated. Within a couple of weeks we will see the results of that experiment. it will be interesting to follow the results in Dr. Gerald’s subsequent reports.

American Rescue Act Provides Ways to Improve Post-Partum Maternal Health Outcomes

Tucked inside the American Rescue Plan is a Medicaid state plan option allowing states to offer pregnancy-related Medicaid coverage for one year after the end of pregnancy, extending coverage well beyond the current cutoff of 60 days postpartum.

The option will become available to state Medicaid programs beginning April 1, 2022. States can submit a Medicaid state plan amendment (SPA) to receive federal matching funds to cover postpartum people for an additional 10 months after the end of the pregnancy.

Women of color and women living in rural areas are at the greatest risk of experiencing severe maternal morbidity, such as stroke or hemorrhage. Black and Indigenous women are two to three times more likely to die of a pregnancy-related cause as White women, regardless of their insurance coverage at the time of delivery.

A significant portion of pregnancy-related deaths occur more than two months after the end of the pregnancy, after postpartum Medicaid coverage has expired for many pregnant women.

This new option will provide an opportunity to implement evidence-based interventions to help reduce these health disparities and improve the health of all new mothers. We encourage AHCCCS to begin planning to take advantage of this important opportunity.

Journal Articles of the Week

Associations Between Governor Political Affiliation and COVID-19 Cases, Deaths, and Testing in the U.S.

This study examines differences in COVID-19 infection, death, and testing by governor party affiliation across 50 U.S. states and the District of Columbia.  From June through December 2020 Republican-led states had higher disease incidence (RR=1.10, 95% PI=1.01, 1.18); higher COVID death rates (RR=1.18, 95% PI=1.02, 1.31). 

Conclusion: Gubernatorial party affiliation may drive policy decisions that impact COVID-19 infections and deaths across the U.S.


Neutralizing Antibodies Against SARS-CoV-2 Variants After Infection and Vaccination

This study found neutralizing activity of infection- and vaccine-elicited antibodies against 4 SARS-CoV-2 variants, including B.1, B.1.1.7, and N501Y. The these results suggest that infection- and vaccine-induced immunity may be retained against the B.1.1.7 variant. 

Interestingly, the study also found that antibody titers for participants that received the mRNA vaccine were higer than persons with a previous natural infection.


Upcoming Webinar Series: COVID-19 Vaccination and Reaching People with Disabilities

The Association of University Centers on Disabilities, Association of State and Territorial Health Officials and NACCHO are hosting a webinar series on strategies to prioritize people with disabilities in the COVID-19 vaccination effort. Each session is from 1-2 p.m. ET. (10am – 11am AZ time).

  • March 30: Navigation: Promising practices for scheduling and transporting persons with disabilities to COVID-19 vaccination appointments. Register here.

  • March 31: Consideration: Promising practices for vaccinating family members of persons with disabilities and those who are homebound. Register here.

  • April 7: Communication: Promising practices for reducing COVID-19 vaccine hesitancy and disseminating accessible messages. Register here.

  • April 8: Prioritization: Promising practices for educating others about the importance of disability prioritizing in state vaccination plans. Register here.

Governor Ducey & Director Christ Eliminate Virtually All COVID Mitigation Measures

Cities and Counties Are Again Prohibited from Having Mask Mandates

On Friday morning (without consulting county health departments or the hospitals that have been caring for the more than 16,000 persons who have died from COVID-19) Governor Ducey & Director Christ rescinded all remaining COVID-19 mitigation measures in Arizona.

It’s officially a free-for-all in Arizona now. Executive Order 2021-06 eliminated several executive orders and with them all remaining required mitigation measures.

  • Cities and counties are again prohibited from having mask mandates. They said in the press release that the mandates are being phased out. They are not. The mandates are officially gone and cities or counties cannot enforce them.

  • Events of more than 50 people, including youth sports and concerts, DBacks and Suns games etc. will no longer need approval from local governments. Owners can do what they wish.

  • All of the formerly “required” COVID-19 mitigation requirements for businesses are now just recommendations. However, there was virtually no enforcement of them. In effect, those “requirements” were really just recommendations anyway.

  • Bars can now officially resume all regular operations, although most have been doing so for many months now with impunity.

Other former Executive Orders that were rescinded include implementing safety protocols like working from home, monitoring employees for sickness and providing employees with PPE, and requiring the ADHS to implement statewide contact tracing.


So what is he real impact of his decisions today? In terms of the bars, restaurants and nightclubs that are so efficient at spreading the virus – really nothing. Why, you ask?

Because those mitigation ‘requirements’ were just on paper anyway. They were never enforced by the ADHS and for all practical purposes never really existed. Businesses have been and will continue to do what they think their customers expect. They have known for many months that they don’t actually have to follow the mitigation measures ‘required’ by ADHS- because there has never been any enforcement.

Among the tens of thousands of bars, restaurants, and nightclubs that have been violating the ADHS capacity limits and other mitigation ‘requirements’ over the last 6 months there have been less than 20 enforcement actions (and those only happened when videos went viral on Twitter).

Basically, there never have been any enforced limits in Arizona since summer. The Governor’s EO makes it sound like he and she are rescinding requirements, when for all practical matters, they never did exist. At least Director Christ and Governor Ducey are finally being honest that there aren’t any required mitigation in bars, restaurants and nightclubs.


Masks are another matter. There’s no doubt that fewer persons will wear masks in public places now. Mask wearing has normalized somewhat and so some people will keep wearing masks, but they will likely be worn by fewer people now. This will spread the virus more readily.

The decision to prohibit local mandates will cause an increase in spread of the virus. This will be a direct result of the decisions jointly made Friday by the Governor and Director.

In a couple of weeks we will being to see what kind of impact it has on case rates and percent positivity. With about 30% of Arizonans recovered from a COVID infection (in large part because of poor decisions made by Governor Ducey & Director Christ) and another 30% with at least one vaccine- the virus is having a harder and harder time finding new hosts.

Governor Ducey & Director Christ Declining Extra FEMA Vaccine & Assistance

After a Great Deal of Public Advocacy ADHS Capitulates & Will Now Allow Pima County to Work Directly with FEMA on PODs for their Underserved Areas

For the last couple of months FEMA has offered states an opportunity to receive federal resources with which to operate vaccination centers. They offer vaccination resources using several models, ranging from large mega-sites to mobile clinics that can be deployed in underserved areas.

FEMA makes it clear that vaccines used in their centers “… are provided to the states above and beyond the regular allocations” . FEMA also offers states funding, personnel and supplies for their centers.

Many states have taken advantage of these federal resources to help them with their response, but Arizona has been declining FEMA assistance for several weeks now.

The big question is why? We don’t know for sure. Director Christ has made statements about why Arizona has declined assistance, but her remarks directly contradict those of FEMA- who makes it clear that vaccine at their centers are over and above standard state allocations. She also said that FEMA sites have wait times of “four to five hours” which is false.

After these false claims were made in the Arizona Republic by Director Christ last weekend, the FEMA Region 9 administrator pushed back hard in a strongly worded letter to the ADHS Director.

In it, Tammy L. Littrell Acting Regional Administrator, states that:

… I am concerned that our conversations earlier this week did not include the reservations you outlined yesterday when communicating with the press.” 

The letter goes on to specifically dispute each and every false claim about the FEMA program that Director Christ made in the media.


Pima County Health Department has specific resourced plans in place to implement FEMA vaccine centers in some of their most underserved areas. The additional Community Vaccination Centers would be federally supported sites focused on areas with a high Social Vulnerability Index at El Pueblo Community Center and the Kino Event Center.

The FEMA Center would be closely coordinated with local health officials and would come with an additional eight-week vaccine supply, clinical and administrative staff, and 100% federal funding. It would be led by local public health officials that would have oversight of the vaccination mission.

Over a 6 week period the partnership would vaccinate an additional 210,000 people in Pima County – mostly in low income areas where the vaccine access disparities are… doubling the vaccine supply to the county over that time period!

Pima County specifically asked Director Christ to submit their request to FEMA, yet she refused to do so until Friday, when she agreed to “allow” Pima County to work directly with FEMA on the PODs.

It was puzzling to many of us in public health why she would refuse to allow Pima County to ask FEMA for these critical resources. Perhaps it was because of her long-standing dispute with Pima County about ADHS’ refusal to reimburse Pima County for $7.6M in COVID-19 testing costs between December 21, 2020 and January 15, 2021.

Additionally, persons from Pima County have been among the most vocal in the state about Director Christ’s and Governor Ducey’s decision-making during the pandemic, perhaps that is part of it.

UPDATE: After a great deal of negative media attention, Director Christ released a statement on Friday afternoon that she “… is delegating authority to Pima County to work independently with FEMA to operate vaccine PODs”.

We shall see what comes out of this now that the state health department is out of the way.

It’s Official: COVID-19 Has Been the Leading Cause of Death in AZ During the Pandemic

Last month one of our members (Allan N. Williams, MPH, PhD)  analyzed ADHS vital statistics data and developed our newest epidemiology report entitled: “How Do COVID-19 Death Rates Compare to the 15 Leading Causes of Death in Arizona?”  

Not surprisingly, the report found that COVID-19 had been the leading cause of death in Arizona during the first 10 months of the pandemic (Nationally, it has been the 3rd third leading cause of death). 

Last week he updated the data in the report using the 12-months of data since the pandemic began – comparing rates to all cause death rates for the last complete year for which data is available (2019).

You can in this chart that COVID death rates have been the leading cause of death in AZ during the pandemic, out-stripping both heart disease and cancer by a wide margin. This is not the case in most states and in the U.S. as a whole. For most states and the U.S., COVID is still behind cancer and heart diseases.

This sobering statistic highlights the deadly effect that failure to implement evidence based interventions has had in Arizona.

For a detailed review of the policy and operational failures of the last year you can read our summary report entitled THE 2020 COVID-19 PANDEMIC IN ARIZONA: THE YEAR IN REVIEW.

Dr. Gerald’s Weekly Epidemiology & Hospital Report

Here is a link to this week’s report. Below is a synopsis, and as always, excellent graphs are in the full report.

Arizona is beginning to transition from a period of substantial risk to one of moderate risk with continuing, albeit smaller, improvements in case counts expected over the coming weeks.

Hospital capacity remains adequate to meet Arizona’s foreseeable needs; however, the backlog of non-Covid care has yet to be fully addressed as evidenced by unseasonably high hospital occupancy.

As of March 19th, 700 (8%) of Arizona’s 8587 general ward beds were occupied by Covid-19 patients, a 14% decrease from the previous week’s 814 occupied beds (Figure 4 and Figure 5 Panel A). Another 978 (11%) beds remained available for use. The number of available beds is lower than the previous week’s 1011 beds.

Covid-19 occupancy has dropped by 86% from its January 11th peak of 5082 ward patients. Nevertheless, hospitals remain above seasonal occupancy.