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This time last year, the world was heading into a pandemic that would upend everything and cost 1.9 million lives — and counting. The promise of the new year is that vaccines are finally here and offer a way out. 

But the vaccination campaign has gotten off to a sluggish start in the U.S. Instead of 20 million people vaccinated by the end of 2020 — a frequent promise of the Trump administration — only around 

 have gotten their first dose so far. Explanations for this include 

 and the need to train health care workers to give the shots. 

Vaccine rollout hasn't been as bad as it seems

But case and death counts keep rising, making widespread vaccination more urgent than ever. So how can the U.S. jump start the COVID-19 vaccination campaign? 

NPR talked to more than a dozen public health experts to get their views. Here are their takeaways.

All the way back in September, Centers for Disease Control and Prevention Director Robert Redfield 

 that "the time is now" to get billions of dollars for coronavirus vaccine distribution out to states. 

But that didn't happen, and public health officials say the delay in federal funding is in part to blame for the slow start of the vaccination campaign. This week, the federal government announced that some of the nearly $9 billion included in the December COVID-19 relief package is 

"We are looking forward to getting that money, which will be critical for several aspects of our response," 

, Pennsylvania's secretary of health and president of the Association of State and Territorial Health Officials told NPR in a press briefing. She says the money will be used to contract companies to run community vaccination clinics and execute on a vaccine public awareness campaign.

 says the money will allow his state "to purchase some vehicles for mobile vaccination, to bring on additional personnel," and do outreach to communities of color.

Officials expect that it's going to take at least three weeks for that money to get 

, and then more time to get to the frontline of the vaccine effort. When it arrives, experts expect the campaign to ramp up quickly.

The two vaccines currently authorized in the U.S. — made by Pfizer and Moderna — are complicated to handle. They're both frozen — one requires storage at 

 and dilution in the field — they require patients to be observed for at least 15 minutes after getting their shot, and patients need to return several weeks later for a second dose. 

The complexity has slowed things down, and new, simpler vaccine candidates on the horizon could help. 

 for how to properly administer the two available vaccines came out at the same time that doses were arriving.

"It's not that the vaccines are rolling off the trucks and we're able to administer it immediately," says 

, deputy secretary of public health services at the Maryland Department of Health. "Training is important to make sure that we deliver the right amount of vaccines for every individual and do it in a safe manner and as efficiently as possible without waste."

Even as health care workers get the hang of handling these Pfizer and Moderna vaccines, officials are looking ahead to other promising vaccine candidates that would add to the available supply.

We have heard that both Johnson & Johnson as well as AstraZeneca plan to submit their proposals for an [Emergency Use Authorization] by the end of this month or in February," says Levine of ASTHO. "We'll see how the science is and what the FDA and the CDC decide — but potentially the distribution of more vaccines, especially the one-dose Johnson and Johnson [vaccine], would ramp things up significantly."

Neither of these vaccines have the ultracold storage requirements that the Pfizer vaccine does — they can be kept at refrigerator or freezer temperatures for longer, giving planners much more flexibility.

, health policy professor at Yale University, agrees that there's a lot of enthusiasm for the Johnson & Johnson vaccine. "A one-dose vaccine would be a game changer for the vaccination program here in the United States in the months ahead," he says.

Since many vaccine candidates are already being manufactured and can be ready to go once federal health agencies give the green light, the stock of vaccine that's available could increase very quickly. 

And once there are more vaccine doses to go around, "we can distribute more generously to doctors' offices, federally qualified health care centers, rural health centers, chain pharmacies, retail pharmacies, community pharmacies — we can't distribute to all of those places if we don't have enough quantity," says Kentucky public health commissioner Dr. Steven Stack. 

So far, the vaccines have been mostly delivered to hospitals to reach front line health workers, and long-term care facilities for residents and staff. 

, are starting up "megasites" — vaccination clinics designed to vaccinate hundreds or thousands of people each day. More of these venues will likely crop up across the country as federal funding allows health officials to hire temporary staff, and pay for space and supplies, and as soon as the supply of vaccine is steady enough to keep these clinics stocked at full volume.

There should be "mass vaccination clinics in high school gymnasiums, convention centers, and mall parking lots in every county in America," says Schwartz. These types of sites will be essential as the pool of people eligible to get vaccinated expands. 

The key to making this work at the scale needed is federal funding and logistical support, Schwartz argues, since hospitals are already overstretched caring for COVID-19 patients, and local and state governments don't have the money to pull it off on their own.

If vaccine providers have doses of vaccine ready to go, but no one is scheduled to receive them, that's a problem. It's also a problem if there are patients scheduled — but no vaccine.

"[Once], our Moderna shipment just didn't show up; we have no idea where it went," says 

, a medical officer at Stanford Children's Hospital who serves as a vaccine adviser for the CDC and California. "We were planning around those doses so we had to slow down for a little bit."

A match between supply and demand is key to making the vaccination campaign go smoothly. There was a major hiccup at the federal level early on: Gen. Gus Perna, the logistics lead of Operation Warp Speed, 

 for telling states that more vaccine would be available than was actually ready to go. State and local officials say predictability has gotten better, but there are still inconsistencies.

A steadier supply of vaccine doses would help vaccine providers plan so that there are patients ready to go for every dose that comes in. 

5) Unleash the public awareness campaigns

There's one more key to a speedy vaccine rollout: a public ready and eager to get vaccinated. Health officials in Kentucky, Ohio and other states say that hesitancy has slowed down their vaccination campaigns.

To combat misinformation and reassure the public that the vaccines are safe and effective, comprehensive public awareness campaigns will be crucial. That includes national efforts from the 

 planned by the Ad Council, alongside state and local efforts to get the word out.

But expert says that's no reason to fear it

How vaccine misinformation spread to the mainstream

"States need to have vaccine confidence outreach teams that are fully resourced to go out into communities and educate members of the public about the importance of these vaccines," says 

, deputy director of the nonprofit advocacy group the Immunization Action Coalition. Those teams will need "to answer their questions, to dispel myths, to encourage them to make a decision to be vaccinated and to communicate with them about how they receive the vaccine in their own state."

The effort needs to be state-specific since every state has a slightly different distribution plan, says 

, chief of government and public affairs at NACCHO, the National Association of County and City Health Officials. Otherwise, "people are watching the nightly news and really trying to figure out, 'Why do these people have access but these people [in another state] don't?' "

In Michigan, at the Washtenaw County Health Department, there's a team dedicated to answering emails and calls about vaccine distribution. "We've been inundated for weeks now with questions about 'When and where can I get my vaccine?' " says spokesperson 

. "It's been a challenge because people want and expect us to be able to tell them this date and this time, and we're just not there yet."

As the long-awaited federal funding comes in and health departments are able to ramp up vaccine administration and activate their communication plans, they're hoping to be able to get those answers out to the public soon.

Rob Stein and Allison Aubrey contributed to this report.

Health

COVID-19

Selena Simmons-Duffin

Author

Pien Huang

With case and death counts still surging, the pressure is on to vaccinate as many people as possible. Here's what it will take to get more Americans their shots, fast.

Here's how the U.S. can jump-start its sluggish COVID-19 vaccine rollout

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