When KC Care Health Center ramped up its COVID-19 vaccine rollout earlier this year, staff couldn't keep up with demand. Doses went into patients' arms as soon as they came in.
So when Missouri made all adult residents eligible for the vaccine a week-and-half ago, Adria Edwards, director of special projects for the federally qualified health center, assumed demand would skyrocket.
Instead, Edwards said demand has fallen by half or more - despite the fact only one-third of Missourians have gotten at least one shot.
"I think that the people who were very interested in getting the vaccine found a way to get it before now," Edwards said, "and so now, I think we're at the point where it's going to be the individuals who are maybe less comfortable or more distrustful of our health care system."
Vaccine clinics across the state have faced a similar predicament. Last week alone, thousands of appointments were available across St. Louis County to Columbia, with health departments working to spread the word.
"We knew the switch was going to be flipped. I thought it might be more of a dimmer switch," said Christopher Ave, a spokesman for the St. Louis County Department of Public Health. "But as it turns out, it wasn't a dimmer switch."
State officials have forecast for weeks that vaccine supply would soon outpace demand, and last week was the first time that order requests from providers dipped, said Lisa Cox, a spokeswoman for the state Health Department.
And while an April poll commissioned by the Missouri Hospital Association found nearly 30 percent of respondents said they didn't plan to seek a vaccine, hesitancy is far from the only factor affecting demand.
Vaccination rates are still lagging among certain demographic groups, like Black Missourians, and slowing among others like those 65 and older, despite Missouri's attempts to prioritize the vulnerable.
Barriers to access still need to be broken down - like providing more options for people with demanding work schedules or a lack of transportation and info in language options for non-native English speakers.
It wasn't until Tuesday that the state launched a Spanish-language version of its vaccine registration system, Vaccine Navigator, with additional languages on the way.
More than 75,000 are registered with the system, and of new registrants, 33,000 identified as being homebound or needing transportation assistance, Cox said Tuesday on a call with vaccine providers. The state has compiled a list of resources to assist with getting a ride.
It's those gaps that providers are now focusing their efforts on, moving from an approach of larger vaccination events to adding more tailored clinics to meet the needs of specific groups. At a federal level, President Joe Biden called for employers to give workers paid time off to get vaccinated or recover from the shot.
Riisa Rawlins-Easley, chief of staff for the St. Louis Regional Health Commission, said it's an opportunity to see where the medical system has historically not reached communities and engage those groups.
The St. Louis Regional Health Commission has put a focus on building bridges between patients, providers and community - and has advisory boards tailored to each. It's a similar spirit of collaboration they're carrying forward with education campaigns around the vaccine and a new webpage that puts resources in one place to connect organizers with providers who can help host a community vaccination event.
"I think what we lack is a real centralized, coordinated approach to ensuring that the supply is matched well with folks who are interested," Rawlins-Easley said, later adding: "And so now, what I'm excited about is that we are - late, but better late than never - trying to coordinate all of the moving pieces so that supply gets to demand to try to close some of those loops."
Hesitancy and access
For Bilingual International Assistant Services, which works with primarily elderly, immigrant communities in St. Louis, hesitancy and barriers to access exist simultaneously.
"Both scenarios are equally true," said Jason Baker, the organization's executive director. "We are seeing clients who want to get the vaccine, who are running up against structural barriers, the main one being language access. Another one being transportation."
At the same time, Baker said hesitancy can be difficult to chip away at, like distrust in government solutions to large scale problems given some groups' history in their home countries.
In February, Lori Stoll, health promotion coordinator for Catholic Charities of Central and Northern Missouri, the only refugee resettlement agency in Columbia, embarked on calling more than 100 refugees to survey not only their interest in receiving a vaccine but what hurdles existed.
"From that survey, we gained that there was some hesitancy, but moreover, there was a lack of any information being targeted to their populations," Stoll said.
With the pandemic upending traditional points of congregation, like senior centers or English classes, getting information out requires more time-intensive, one-on-one phone calls. Bilingual International is used to helping clients navigate complicated systems, like Medicaid, but with the vaccine rollout, new information comes out daily.
Through Catholic Charities of Central and Northern Missouri's survey, the agency has been able to pinpoint avenues to disseminate info, like fliers translated into six languages, helping clients get to appointments and holding an information session with the Columbia/Boone County Department of Public Health and Human Services on Wednesday.
"It's important to all of us, for everyone, regardless of culture, to have access to the vaccine and access to health information," Stoll said. "And to treat each person with dignity and give them information in a level that they could understand."
The ultimate goal: to host a vaccination clinic at the agency's office in the next few weeks.
Expanding options
Much of the vaccine rollout's model has been based on getting people to the vaccine, rather than bringing it to them. Cox said that's, in part, because of the large quantities the vaccine comes in - a tray of 1,170 doses for Pfizer, 100 for Moderna at minimum - make it more difficult to supply providers with smaller numbers.
Cox said smaller shipment sizes would help the vaccine get to more providers who might be more convenient for residents. While mass vaccination events work for many, it can't be the only route, providers said, stressing smaller events at trusted community centers are also needed. Improved accessibility is what vaccine providers are aiming to achieve by expanding the settings where they offer it.
"It's in your doctor's office, it's all over the place, rather than requiring people to go to events at certain times," Cox said.
Edwards said the KC Care Health Center has had to take a more proactive approach.
"Now that we have the supply, it has to be way more than just having a link up on our website," Edwards said.
In Jackson County, the health department is adapting by offering clinics later in the evening and changing locations, said Mariah Cox, a spokeswoman for the department. It's also partnering to vaccinate individuals in detention facilities in addition to the uninsured and people experiencing homelessness through Care Beyond the Boulevard's mobile medical clinics.
In St. Louis County, the health department has eliminated pre-registration, and on Monday, it announced walk-up clinics. In addition to planning more events in collaboration with community providers and targeting specific groups, like those hard of hearing, it's also vaccinated more than 200 homebound residents and their caregivers through a partnership with fire districts and EMS, and has brought vaccine to senior living facilities that weren't reached by the federal partnership with retail pharmacies.
"Just because you open a site, it doesn't mean you're going to get vaccine to the most vulnerable," Ave said. "And that's why you have to take these extra steps of identifying, where are they? And how can we get to them?"
The Missouri Independent is a nonprofit, nonpartisan news organization covering state government and its impact on Missourians.