Here in the U.S., average daily rates of COVID-19 vaccines administered has decreased from a peak of 3.3 million on April 11 to 1.8 million in May. Approximately 1.3 million people per day are achieving fully vaccinated status (i.e., having received either both doses of Pfizer/BioNTech or Moderna vaccine or one dose of the Johnson & Johnson/Janssen vaccine). On May 23, the U.S. reached over 285.7 million total doses administered with 163.3 million persons (49.2% of the total U.S. population) having received at least one dose and 130 million persons (39.2% of the total U.S. population) being fully vaccinated. Among those individuals aged 65 years and older, progress appears to be stalled with 85.4% of individuals having received at least one dose and 74% being fully vaccinated. States with the highest proportions of their population having received one or more doses include Vermont (66.2%), Hawaii (63.5%), Massachusetts (63.5%), New Hampshire (62.1%), and Connecticut (60.3%).

Increasingly, the consensus is that the U.S. has reached a “vaccine tipping point” where supply has finally surpassed demand. There are notable differences among states and regions, however, in terms of when they reached this tipping point and the level of vaccine-uptake they have achieved at their respective peaks. According to the Kaiser Family Foundation (KFF), between April 22 and 29, the rate of first dose administration per 100,000 persons had dropped by 17% nationally and for almost every state. Many of the states with even the highest rates of vaccination have seen daily vaccine administration rates start to taper with 60% or more of their adult population at least partially vaccinated. In the 13 states with the lowest vaccine coverage (i.e., less than 50% of their adult population has received at least one dose), most have also seen drop-offs in their daily rates. Taken together, this shows that in the months ahead we could see clearer state-by-state differences in vaccine coverage and, as a result, difference in the rates of COVID-19 incidence, hospitalizations, and death.

In the first months of the vaccine rollout, many communities faced challenges in securing and reaching an appointment. Inequities in vaccine uptake have persisted across race, ethnicity, income, disability, etc. While race and ethnicity data are frequently unknown or unreported in the Centers for Disease Control & Prevention (CDC) COVID Data Tracker (the CDC’s tool for sharing key COVID-related data with the general public), White/Non-Hispanic persons reportedly represent a disproportionate share of those to receive a first dose and be fully vaccinated. For those who remain unvaccinated, there are a myriad of reasons why, some of which may vary among key demographic groups. For example, in recent KFF polling, unvaccinated Hispanic adults were about twice as likely as to say they want to get a COVID-19 vaccine as soon as possible compared to White or Black unvaccinated adults. Yet compared to White adults, larger shares of unvaccinated Hispanic adults reported concerns about missing work due to possible side effects, being required to pay out of pocket for the vaccine, or having trouble reaching a vaccination site. To learn more about effective communication strategies that can be used to address COVID-19 vaccine-related concerns and access challenges, please see this related AG Journal article.

On May 10, the FDA expanded the authorization for the Pfizer/BioNTech COVID-19 vaccine to include adolescents aged 12 years and older (the vaccine was already authorized for individuals 16 years and older). Phase III trial data from Pfizer/BioNTech demonstrated an 100% efficacy in preventing symptomatic COVID-19 among the 2,260 children aged 12 to 15 years of age who participated. In terms of potential side effects, trial participants had very similar experiences as in adults. The CDC, including the Advisory Committee on Immunization Practice, an independent body of medical and public health experts that develop recommendations on the use of vaccines in the U.S. civilian population, quickly updated their guidance accordingly. This paved the way for adolescents to join adults in getting vaccinated across the U.S. beginning on May 13. Within the first week following the updated guidance, an estimated 600,000 children aged 12 to 15 years of age received a shot.

Of note, Pfizer/BioNTech also announced that they anticipate requesting yet another expansion in their authorization for children 2 to 12 years of age in September 2021. Manufacturers of the other two vaccines currently authorized in the U.S. are also testing their vaccines in children. Moderna announced its own trial among children 12 to 18 years of age in December 2020 and has been conducting a separate study involving children 6 months to 12 years of age. Johnson & Johnson/Janssen, meanwhile, plan to test their vaccine in a small study of adolescents first, followed by younger children.

On May 13, the CDC announced an expansive revision to their guidance for fully vaccinated individuals stating that they may resume most activities without wearing a mask or social distancing regardless of whether those activities are indoors or outdoors, except where required by federal, state, local, tribal, or territorial laws, rules, and regulations. This revised guidance also addresses local businesses and workplace. The CDC continues to recommend that individuals who are not vaccinated take COVID-19-related precautions and that fully vaccinated individuals should still do so in certain settings (e.g., airports). This updated guidance builds on previous recommendations that fully vaccinated individuals need not test or quarantine before domestic travel or after a known exposure. It also reflects the latest available real-world data that strongly indicates that fully vaccinated individuals are significantly less likely to get or transmit COVID-19 and that the currently authorized vaccines perform very well against known variants of concern.

Responses to and adoption of this latest guidance has varied. Some states immediately announced plans to lift mask mandates for fully vaccinated individuals, while other states intend to wait for a thorough assessment of more data regarding vaccine uptake and COVID-19 incidence in their jurisdiction. For the foreseeable future, state and local governments as well as businesses will likely adapt their policies in a patchwork and rolling basis. In many settings, there is still no uniform or reliable way to verify who is and who is not vaccinated. Not all states have robust immunization registries that are able to exchange data with electronic health records or other databases that might be used by healthcare providers, employers, schools, and businesses to confirm vaccination status. Moreover, the CDC-created COVID-19 vaccination cards were never intended to serve as proofs of vaccination and have already been falsified and even sold online. As such, ensuring compliance with different guidance based on vaccination status will be extremely challenging in practice and largely based on an honor system.

In the weeks ahead, members of the attorney general community should monitor and be aware of the following possible key events related to the vaccines’ rollout:

• Supply of COVID-19 vaccines increasingly exceeding demand. As a result, a concerted effort to address individual and collective hesitancy and barriers in accessing the vaccines will become even more critical.
• Further updated guidance released by the CDC regarding the need for non-medical interventions (e.g., mask wearing, social distancing) by fully vaccinated and unvaccinated individuals generally and within specific settings.
• Additional vaccine manufacturers possibly seeking authorization in the U.S., including the two-dose AstraZeneca/University of Oxford and Novavax vaccines. Both Novavax and AstraZeneca/University of Oxford have reported delays in seeking FDA authorization and/or meeting anticipated production timelines.
• Further increased vaccine supply secured by the U.S. government via new or amended contracts with manufacturers in preparation for younger children’s vaccinations and/or possible boosters.
• Additional data gathered and published regarding vaccine efficacy against COVID-19 variants as well as rates of transmission and disease severity for those variants.
• Possible increases in the number of schools, employers, etc., requiring proof of COVID-19 vaccination for individuals returning to in-person activities. For more information regarding the legal and policy implications of the COVID-19 vaccine, please see NAAG’s materials from a related training held in December 2020.
• Additional data gathered and published regarding the long-term effectiveness of existing COVID-19 vaccines (i.e., when or if individuals will need to be revaccinated).

Throughout 2021, NAAG will continue to provide informational updates and training opportunities to the attorney general community as COVID-19 vaccine distribution and related legal issues evolve. For more information on NAAG’s response to the COVID-19 pandemic, visit NAAG’s public health-related updates.