Issuu

Table of Contents About Purdue Policy Research Institute ......................................................................................................................................... 3 Issue Overview ............................................................................................................................................................................................ 4 Analysis of COVID-19 Infections and Vaccinations in Indiana......................................................................................... 4 Indiana Vaccination Rates by Race ......................................................................................................................................... 5 Case percentage vs Vaccination percentage across Indiana counties .................................................................. 6 Infection Rates in Indiana Counties by Race ....................................................................................................................... 7 Racial disparities in vaccination rates by County.............................................................................................................. 8 Comparing COVID-19 positivity rates/vaccination rates ............................................................................................... 8 In Summary ....................................................................................................................................................................................... 10 Policy Considerations for Legislators .............................................................................................................................................. 11 1.

Outreach and Combating Misinformation/Disinformation..................................................................................... 11 Policy considerations: .................................................................................................................................................................. 13

Vaccine hesitancy/intention................................................................................................................................................. 13 Policy considerations: ...................................................................................................................................................................17

3. Cultural attitudes to public health measures like mask-wearing can reduce infections even in the face of vaccine hesitancy..................................................................................................................................................................17 Policy considerations: .................................................................................................................................................................. 18 4.

Vaccination Records ................................................................................................................................................................ 18 Policy considerations: .................................................................................................................................................................. 18

Current Indiana Initiatives related to COVID-19 ........................................................................................................................ 19 Indiana Department of Homeland Security: Public Assistance Grant Program ................................................... 19 Indiana Office of Community and Rural Affairs: Covid-19 Response Program ...................................................... 19 Back on Track Indiana ..................................................................................................................................................................... 20 Executive Order 21-21: Establishing the Governor's Public Health Commission ................................................. 20 Executive Order 21-19: Further Continuation of Limited Provisions to Address the Impact and Spread of the Coronavirus Disease (COVID~19) ...................................................................................................................................... 20 References ................................................................................................................................................................................................... 21

List of Tables Table 1: Comparison of United States and Indiana metrics related to COVID-19 ....................................................... 4 Table 2: Comparison of total COVID-19 infections and fatalities among United States, Japan, Korea, and China ...............................................................................................................................................................................................................17

List of Figures Figure 1: COVID-19 infections in Indiana by the three dominant racial groups ............................................................ 5 Figure 2: Relationship between cases and vaccinations among the three largest IN racial groups .................. 6 Figure 3: COVID-19 infection rates among three largest racial groups by county ...................................................... 7 Figure 4: vaccination rates by county across the three largest racial groups. .............................................................. 8 Figure 5: Ratio of positive case percentage/vaccination percentage by county across three largest racial groups.............................................................................................................................................................................................................. 9 Figure 6: Ratio of vaccination percentage/positive case percentage by county across three largest racial groups.............................................................................................................................................................................................................. 9 Figure 7: State-wide trends in vaccinations; Source: Indiana State Department of Health Vaccine Dashboard https://www.coronavirus.in.gov/vaccine/2680.htm........................................................................................ 11 Figure 8: Plot of those in each state unwilling to accept a vaccine, against the percentage of tweets from that state that contain low credibility sources. Source: Indiana University’s OSoMe’s Covaxxy tool: https://osome.iu.edu/tools/covaxxy ............................................................................................................................................... 12 Figure 9: Plot of percentage of tweets from the state of Indiana that contain low credibility sources. Source: Indiana University’s OSoMe’s Covaxxy tool: https://osome.iu.edu/tools/covaxxy ................................. 12 Figure 10: Plot of those in the state of Indiana unwilling to accept a vaccine. Source: Indiana University’s OSoMe’s Covaxxy tool: https://osome.iu.edu/tools/covaxxy ............................................................................................. 12 Figure 11: Estimated vaccine hesitancy rates in Indiana by county. Yellow Star marks the location of Tippecanoe county. Source: Office of the Assistant Secretary for Planning and Evaluation (ASPE) https://aspe.hhs.gov/reports/vaccine-hesitancy-covid-19-state-county-local-estimates ................................... 14 Figure 12: Social Vulnerability Index in Indiana by county. Yellow star marks the location of Tippecanoe county. Source: CDC https://data.cdc.gov/stories/s/Vaccine-Hesitancy-for-COVID-19/cnd2-a6zw/ ......... 14 Figure 13: Percent share of adults that experienced loss of employment income between April and May 2021. Source: https://www.kff.org/coronavirus-covid-19/issue-brief/implications-of-covid-19-for-socialdeterminants-of-health/ ....................................................................................................................................................................... 15 Figure 14: Percent share of food insufficiency in a household between 2020 and 2021. Source: https://www.kff.org/coronavirus-covid-19/issue-brief/implications-of-covid-19-for-social-determinantsof-health/ ..................................................................................................................................................................................................... 16 Figure 15: Percent share of households that found it difficult to pay usual household expenses between 2020 and 2021. Source: https://www.kff.org/coronavirus-covid-19/issue-brief/implications-of-covid-19for-social-determinants-of-health/.................................................................................................................................................. 16

ABOUT PURDUE POLICY RESEARCH INSTITUTE

The Purdue Policy Research Institute (PPRI) connects innovative data science and transdisciplinary researchers from the social sciences, humanities, and STEM disciplines with policy influencers to develop and assess policies, positively impacting grand challenges. Launched in 2010, PPRI catalyzes and leverages extant policy-relevant transdisciplinary research among members of the Purdue research community, facilitates enduring connections among local and global actors, and generates impact on policymaking and beyond. We are guided by the principle that policy development must consider the interdependencies among technological, economic, ethical, and social factors.

Together with collaborators in academia and the public and private sectors, PPRI inspires the development of non-partisan policies that solve pressing global challenges.

Contact us: email: ppri@purdue.edu web: https://www.purdue.edu/discoverypark/ppri/ blog: https://www.purdue.edu/discoverypark/ppri/blog/ Twitter: @PurduePPRI Facebook: @purduepolicyresearchinstitute Instagram: @purdueppri

ISSUE OVERVIEW Vaccine options for COVID-19 began to emerge at the end of 2020, with the US FDA issuing emergency use authorization (EUA) for the Pfizer-BioNTech COVID-19 Vaccine on Dec 11, 2020. According to the FDA, “The vaccine contains a small piece of the SARS-CoV-2 virus’s mRNA that instructs cells in the body to make the virus’s distinctive “spike” protein. When a person receives this vaccine, their body produces copies of the spike protein, which does not cause disease, but triggers the immune system to learn to react defensively, producing an immune response against SARS-CoV-2.” On Dec 18, 2020, the FDA announced EUA for the Moderna COVID-19 vaccine, which is also based on mRNA science. On Feb 27, 2021, the FDA issued an EUA for the Janssen COVID-19 Vaccine. While the first two vaccines require 2 shots roughly 28 days apart, the Janssen vaccine is a single-dose option requiring considerably less frigid storage conditions than the other two. In terms of efficacy, Pfizer and Moderna have shown better efficacy than the single-dose Janssen vaccine, although all three seem to have been equally popular. In light of more infectious and deadly variants of the virus, however, health experts discussed providing booster shots to the Janssen vaccine recipients in an effort to increase efficacy against new variants. In mid-August 2021, the CDC recommended that all immuno-compromised persons be given a third booster shot of the Pfizer or Moderna vaccines to ensure continued protection for those whose immune response may be suppressed due to other health conditions or strong medications. Finally, on August 23, 2021, the FDA granted full approval to the Pfizer vaccine. On September 22, 2021, the FDA released an amendment to the EUA for the Pfizer vaccine, allowing a singledose booster shot six months after the second dose. They provided guidance on the eligibility of booster shot recipients as those 65 years of age and older; individuals 18 through 64 years of age at high risk of severe COVID-19; and individuals 18 through 64 years of age whose frequent institutional or occupational exposure to SARS-CoV-2 puts them at high risk of serious complications of COVID-19 including severe COVID-19. Despite these evolving conditions, it is clear that the remarkable scientific strides made in developing the vaccines have occurred in the backdrop of incredible challenges across the world, in the US, and within Indiana. Over 10% of the US population and Indiana’s population have tested positive for COVID-19 since March 2020, and less than half of the total US population and Indiana population are fully vaccinated (Table 1). In order to reach herd immunity, and to combat highly infectious variants like the Delta variant, at least 70-80% of the community would need to be vaccinated. The US population overall and Indiana population in particular is way behind this target in order to reduce community spread. Table 1: Comparison of United States and Indiana metrics related to COVID-19

Total population (2020) COVID-19 cases as of Sept 15, 2021 Deaths as of Sept 15, 2021 Fully vaccinated as of Sept 14, 2021

United States 328,200,000 41,262,574 660,380 179,289,983

Indiana 6,732,000 913,528 14,482 3,175,016

Source: CDC https://covid.cdc.gov/covid-data-tracker/#datatracker-home and ISDH https://www.coronavirus.in.gov/2393.htm

ANALYSIS OF COVID-19 INFECTIONS AND VACCINATIONS IN INDIANA Scholars at Purdue University analyzed data available from various sources to understand vaccine distribution and delivery in the state of Indiana. This analysis can help formulate policy recommendations to improve vaccine distribution and delivery in Indiana, particularly in the event of another pandemic. The goal of this analysis is to highlight disparities in the number of positive COVID-19 cases and vaccinations among various groups; to understand if access to vaccines was the same across different counties; to

examine if certain racial groups were more vulnerable to the COVID-19 infection, and therefore may be in more urgent need of the vaccine; and to ascertain the reasons for certain outliers in each analysis.

INDIANA VACCINATION RATES BY RACE First, we investigated if there was any disparity for COVID-19 cases and vaccination rates among different races within Indiana by comparing the overall percentage of positive cases and vaccination among each racial group. The COVID-19 data was acquired from https://hub.mph.in.gov/dataset on 6/17/2021. The 2020 Indiana population census data was acquired from https://www.stats.indiana.edu/topic/census.asp. Other races are neglected in this study as most population percentages of each other race is less than 1% of the county total population. Data show that overall, White populations in Indiana had slightly higher infection rates of COVID-19, followed by Black and then Asian 1 populations. On the other hand, Asians were the highest vaccinated among all other racial groups and Black Hoosiers were the least vaccinated (Figure 1).

Figure 1: COVID-19 infections in Indiana by the three dominant racial groups

The Census Bureau defines a person of the Asian race as “having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.”

CASE PERCENTAGE VS VACCINATION PERCENTAGE ACROSS INDIANA COUNTIES Next, we studied if this phenomenon was consistent across all Indiana counties. We plotted the case percentage vs. vaccination percentage among each race for each county. In the following figure, each dot represents a race group for each county. We can see that almost all Asians from all counties had the highest vaccination rate and the least infection rate. In contrast, Black Hoosiers were the least vaccinated and the most infected (as shown in Figure 2).

Figure 2: Relationship between cases and vaccinations among the three largest IN racial groups

INFECTION RATES IN INDIANA COUNTIES BY RACE Next, we plotted the COVID-19 positive case percentage to examine how various racial groups fared in terms of infection rates among various counties. Figure 3 shows that the positive case percentages were similar among each racial group with some outliers. For example, Noble, Davies, and Cass counties had higher infection rates among Asians; Cass, Dearborn, and Posey county among Blacks; and Dubois, Fountain, and Henry counties had higher infection rates among their White populations.

Figure 3: COVID-19 infection rates among three largest racial groups by county

RACIAL DISPARITIES IN VACCINATION RATES BY COUNTY Next, we investigated if there were any disparities in vaccination rates among each of the three dominant racial groups for each county. Figure 4 shows that Asians were the most vaccinated group among almost all counties. With the exception of Morgan county, data from vaccination sites shows that the Black community continues to have the lowest vaccination rates across most counties. Another notable point from this data is that the vaccination rate among Blacks in Morgan county was higher than its total Black population. Data also suggests that some counties were experiencing long wait times during this period, indicating a mismatch between demand and supply.

Figure 4: vaccination rates by county across the three largest racial groups.

COMPARING COVID-19 POSITIVITY RATES/VACCINATION RATES To further illustrate the differences between positive case rates and vaccination rates among the three most populous racial groups across each county, we plotted the ratio of positive case percentage/vaccination percentage (Figure 5) and vaccination percentage/case percentage (Figure 6) among each race for each county. Figure 5 shows that Asians were more vaccinated and less infected. In contrast, Figure 6 shows that the Black population was more infected, while having fewer vaccinations. While distribution of vaccines not meeting the demand from the region, people with means of transportation will travel to get vaccination. Tracking people’s residential location (city, zip code, county) at each vaccination sites are important to better monitor and support the vaccination process in each region.

Figure 5: Ratio of positive case percentage/vaccination percentage by county across three largest racial groups

Figure 6: Ratio of vaccination percentage/positive case percentage by county across three largest racial groups

IN SUMMARY This data raises several noteworthy questions: ● How can the state and county health departments provide guidelines for those infected with COVID19? For example: how soon after their infection can they receive a vaccine? Or if already vaccinated, a booster, if eligible as per the CDC’s latest guidelines? ● Why are vaccination rates among Blacks low across all countries? What are the vaccination rates among Black men versus Black women? ● Data clearly shows that Blacks have had higher infection rates in Indiana and lower vaccination rates. Is lack of clear guidelines about vaccines for those already infected a contributing factor to this issue? ● Why have Asians been more likely to get vaccinated? What are the vaccination rates among Asian men versus Asian women? ● How can vaccination sites track and report more accurate data to help design a better response strategy for the state? ● How can many of Indiana’s public and private universities help? ● How can we get good data to monitor in real-time the vaccination process and quickly respond to supply chain issues from local regions? ● We address some of these questions in the following policy considerations.

POLICY CONSIDERATIONS FOR LEGISLATORS There are several policy considerations that have emerged from analyzing the COVID-19 infections and vaccination rates in the state of Indiana.

1. OUTREACH AND COMBATING MISINFORMATION/DISINFORMATION Vaccines began to be offered to Americans free of cost in December 2020, although the roll out was initially based on age and occupation; first priority was given to the oldest residents and frontline workers. These guidelines were decided by the state governments, with the federal government coordinating the vaccine distribution. Every few weeks, the Indiana State Department of Health revised its eligibility criteria, with all age groups being eligible to get the vaccines in the middle of April 2021. This period also coincided with the highest demand for the vaccine (see Figure 7). Unfortunately, demand for the now-readily available vaccines has dropped considerably since the middle of April, even though appointments for vaccines are no longer required, and most commercial pharmacies are now also offering walk-in appointments for COVID-19 vaccines. Despite that, Indiana recorded only 5598 new fully vaccinated individuals within 24 hours in the state as of September 14, 2021, which is a fraction of the demand in April (see Figure 7).

Figure 7: State-wide trends in vaccinations; Source: Indiana State Department of Health Vaccine Dashboard https://www.coronavirus.in.gov/vaccine/2680.htm

Over the last 18 months, it has become apparent that in addition to the deadly pandemic, the global community has had to battle a widespread and dangerous infodemic that has spread misinformation/disinformation, leading to severe consequences (Houlden et al., 2021; Loomba et al., 2021). This dire situation led the WHO, UN, UNICEF, UNDP, UNESCO, UNAIDS, ITU, UN Global Pulse, and IFRC to issue a joint statement highlighting the severe harm caused by COVID-19 related misinformation/disinformation. They called on UN Member States to mitigate this harm and formulate action plans to combat the infodemic. Thus, inoculation against the COVID-19 virus as well as the infodemic is critical for individuals and communities to recover in the near future, and to be more resilient long-term to other shocks, not just the current COVID-19 pandemic. The US as a whole, and Indiana in particular have felt the impact of this infodemic. According to a report by Indiana University, almost 82% of their unvaccinated (and with no intention to do so) survey respondents believed that the CDC is hiding negative effects of the COVID-19, and almost 53% believed that the vaccines are causing infertility among women, both of which are incorrect information (Observatory on Social Media, 2021). The latter has been one of the most persistent myths that have been repeatedly shared and widely spread via social media (Brumfiel, 2021). Indiana has both a relatively higher rate of vaccine refusal (Figure 10), and high spread of misinformation via low credibility sources, including social media (Figure 9), which falls roughly in the middle of a plot of all the US states (Figure 8). The viral spread of misinformation regarding COVID-19, its cure, and its vaccine

has been detrimental to a safer and healthier community. Therefore, in order for the state to emerge out of this pandemic, and for Hoosiers to remain healthy, combating this misinformation/disinformation infodemic head-on is key.

Indiana

Figure 8: Plot of those in each state unwilling to accept a vaccine, against the percentage of tweets from that state that contain low credibility sources. Source: Indiana University’s OSoMe’s Covaxxy tool: https://osome.iu.edu/tools/covaxxy

Figure 9: Plot of percentage of tweets from the state of Indiana that contain low credibility sources. Source: Indiana University’s OSoMe’s Covaxxy tool: https://osome.iu.edu/tools/covaxxy

Figure 10: Plot of those in the state of Indiana unwilling to accept a vaccine. Source: Indiana University’s OSoMe’s Covaxxy tool: https://osome.iu.edu/tools/covaxxy

POLICY CONSIDERATIONS: • • • •

•

Create policy to implement penalties for individuals and entities in Indiana that willfully spread misinformation/disinformation that is detrimental to public health Create policy to hold local and regional news media accountable for willfully spreading misinformation/disinformation in the state that can be detrimental to Hoosiers Create policy to hold social media companies accountable for supporting the spread of misinformation/disinformation in the state Create outreach programs within Indiana in partnership with public libraries, universities, and local governments to have information and media literacy training in communities to help vulnerable citizens be better informed and trained to discern misinformation/disinformation and report it to relevant state agencies for further policy considerations Create a state-wide department for public safety that coordinates with local and county governments in identifying sources of misinformation/disinformation and combat it early on to ensure the safety of all Hoosiers

2. VACCINE HESITANCY/INTENTION Misinformation/disinformation is just one reason for vaccine hesitancy in the US. Religious/cultural beliefs are also playing a huge role. When combined, both have led to high vaccine hesitancy among certain communities, many of whom may be vulnerable to COVID-19 impacts due to health or economic considerations. Combating vaccine hesitancy is therefore incredibly important in order to combat the pandemic. When compared globally, vaccine distribution is extremely uneven; industrialized countries in Europe and the United States have been attempting to vaccinate their own citizens first, while not sharing vaccine information with other nations, causing severe worldwide need and shortage. Some have argued that vaccine hesitancy is a ‘privilege’ other nations do not have, whose residents are desperately seeking COVID-19 vaccines while unvaccinated US residents continue to reject it even with so many incentives being offered (Nabi, 2021). Indiana University’s OsoMe has a COVID-19 hesitancy tool Covaxxy, which has calculated Indiana’s overall vaccine rejection (unwilling to get vaccinated) at almost 21%, with only 46% of the state fully vaccinated as of August 2021. This has been despite repeated efforts by the Indiana State Department of Health to reach out to Hoosiers, like frequent ads on radio and tv, posts on social media, and other outreach campaigns. Interestingly, Indiana is one of the few states that is not offering state-wide cash incentives. A list of state incentives shows many states offering cash lotteries of up to $1 million; thus far Indiana has offered girl scout cookies. Thus, there has been no considerable shift in months in the number of people opting for the vaccine as shown in Figure 7. As shown in Figure 11, vaccine hesitancy in Indiana’s counties vary but mainly fall in the median range; Hamilton and Boone counties are the only ones with less than 10% hesitancy rate. Tippecanoe county, home to Purdue University, has a hesitancy rate of almost 11% as shown in Figure 11. Despite lower hesitancy rate, however, the county still has less than 50% fully vaccinated individuals. This data also shows the CDC’s Social Vulnerability Index (SVI, Figure 12), which summarizes the extent to which as community is socially vulnerable to disaster. According to the CDC, “the factors considered in developing the SVI include economic data as well as data regarding education, family characteristics, housing language ability, ethnicity, and vehicle access.” Tippecanoe county falls in the moderate range of this metric.

County Name: Tippecanoe County, Indiana Estimated hesitant: 10.84% Estimated hesitant or unsure: 15.8% Estimated strongly hesitant: 6.76% Social Vulnerability Index (SVI): 0.49 (Moderate Vulnerability) Level of Concern (CVAC): 0.66 (High Concern) Percent adults fully vaccinated against COVID-19 (as of 06/10/21): 47.8% Demographics: Percent Hispanic: 8.33% Percent non-Hispanic American Indian/Alaska Native: 0.25% Percent non-Hispanic Asian: 8.1% Percent non-Hispanic Black: 5.19% Percent non-Hispanic Native Hawaiian/Pacific Islander: 0.03% Percent non-Hispanic White: 75.83%

Figure 11: Estimated vaccine hesitancy rates in Indiana by county. Yellow Star marks the location of Tippecanoe county. Source: Office of the Assistant Secretary for Planning and Evaluation (ASPE) https://aspe.hhs.gov/reports/vaccine-hesitancy-covid-19-state-county-local-estimates

Figure 12: Social Vulnerability Index in Indiana by county. Yellow star marks the location of Tippecanoe county. Source: CDC https://data.cdc.gov/stories/s/Vaccine-Hesitancy-for-COVID-19/cnd2-a6zw/

In the US overall, people of color have borne the disproportionate impacts of the COVID-19 pandemic, which have often stemmed from decades of health, economic, and racial disparities. The Census Bureau’s Household Pulse Survey has attempted to collect data to track how families and communities have fared in the pandemic. As shown in Figure 13, Figure 14, and Figure 15, between 2020 and 2021, a large majority of

Black and Hispanic households that were surveyed have been the most prone to losing employment income, have food insufficiency, and be unable to pay usual weekly household expenses respectively. They have thus borne the most burdens from the economic fallout of the COVID-19 pandemic. Consequently, Black and Hispanic 2 communities in particular are also most prone to bearing the burden of vaccine inequity, which also explains the low vaccination rates, which are not just because of vaccine hesitancy. Additionally, families with a child in the household fared poorly across all three vectors in this survey as well; it is hoped that these indicators will improve with the deployment of additional aid packages like the American Rescue Plan and the child tax credit. Also, important to note that not all minority groups have the same impacts. In Indiana, for example, vaccination rates among Asians are a very high percentage of their total population in the state, as shown in Figure 1. With many Asians likely having memories of the various SARS outbreaks in recent years, higher rates of mask wearing and vaccinations within the community would therefore not be a surprise. However, higher vaccination rates among certain communities will not be enough. Scientists predict that in order to achieve herd immunity, 80-85% of Americans will need to be vaccinated—it stands to reason that it is very important for federal and state agencies to ensure higher vaccination rates among groups currently not vaccinated.

Experienced loss of employment income in the last 4 weeks Kid in Household Male Female 65+ 45 to 64 26 to 44 18 to 25 Other Race Asian Hispanic Black White Total Population 0

10 April 14- April 26, 2021

April 28- May 10, 2021

Figure 13: Percent share of adults that experienced loss of employment income between April and May 2021. Source: https://www.kff.org/coronavirus-covid-19/issue-brief/implications-of-covid-19-for-social-determinants-of-health/

According to the Pew Research Center, “terms “Hispanic” and “Latino” are pan-ethnic terms meant to describe – and summarize – the population of people living in the U.S. of that ethnic background. In practice, the Census Bureau most often uses the term “Hispanic,” while Pew Research Center uses the terms “Hispanic” and “Latino” interchangeably.” In this data, people of any race could be characterized as ‘Hispanic’.

Food insufficiency in a household 2020-2021 Kid in Household Male Female 65+ 45 to 64 26 to 44 18 to 25 Other Race Asian Hispanic Black White Total Population 0

April 23- May 5, 2020

August 19- August 31, 2020

December 9- December 21, 2020

February 3- February 5, 2021

April 14- April 26, 2021

April 28-May 10, 2021

Figure 14: Percent share of food insufficiency in a household between 2020 and 2021. Source: https://www.kff.org/coronaviruscovid-19/issue-brief/implications-of-covid-19-for-social-determinants-of-health/

Difficulty paying usual weekly household expenses 2020-2021 Kid in Household Male Female 65+ 45 to 64 26 to 44 18 to 25 Other Race Asian Hispanic Black White Total Population 0

August 19- August 31, 2020

December 9-December 21, 2020

April 14- April 26, 2021

April 28- May 10, 2021

February 3-February 15, 2021

Figure 15: Percent share of households that found it difficult to pay usual household expenses between 2020 and 2021. Source: https://www.kff.org/coronavirus-covid-19/issue-brief/implications-of-covid-19-for-social-determinants-of-health/

POLICY CONSIDERATIONS: • • •

•

Identify religious/cultural/ethnic/racial communities that have high vaccine hesitancy or refusal, and create targeted outreach and literacy campaigns via ISDH and county health departments Identify local community groups, church groups, and other local leaders to enhance outreach Allocate funding for mobile vaccination clinics within communities, in neighborhoods, and within religious spaces and community centers to make vaccines more accessible with encouragement coming from trusted community members Create state-wide policy to provide paid time-off to get the vaccine and to recover from any side effects. This can help combat additional hesitancy in low-income workers who may be hesitant to get a vaccine for fear of loss of jobs or revenue. Literacy programs among school-age children can also have a positive impact in changing adult views on the safety and efficacy of vaccines in general, and COVID-19 vaccines in particular

3. CULTURAL ATTITUDES TO PUBLIC HEALTH MEASURES LIKE MASK-WEARING CAN REDUCE INFECTIONS EVEN IN THE FACE OF VACCINE HESITANCY In the last two decades, both mask-wearing and vaccine acceptance have developed cultural dimensions globally—they are considered normal in many East Asian cultures. There is a centuries-long history of influenza and other SARS infections wreaking havoc in East Asia, as a consequence of which mask-wearing in public is common-place (Griffiths, 2020; Leung, 2020; Wong, 2020). It is most often considered considerate of others, even if you have the common cold (Beglin, 2020). In countries like Japan, where rapid industrialization in the 1950s led to severe air pollution, mask-wearing is very common. It is estimated that Japan residents spend roughly $230 million in surgical masks a year (Yang, 2014). Their neighbors, especially China and Korea have also adopted the practice over the years. In fact, the Ministry of Health, Labor and Welfare in Japan has a webpage dedicated to ‘Cough Etiquette’ that encourages residents to wear a mask when sick (Ministry of Health Labour and Welfare, n.d.). As a result, getting the public to wear masks at the start of the pandemic was relatively easier for many East Asian governments, and some have argued, may have led to fewer infections and spread than if the community had not been wearing masks (Griffiths, 2020; Wong, 2020). The numbers in Table 2 show a stark difference in infections and fatalities among United States, Japan, Korea, and China. Therefore, while we work on combating vaccine hesitancy among Hoosiers, the best way to keep them safe would be to encourage mask-wearing, and also change public perceptions in wearing masks. Additionally, encouraging Hoosiers to wear masks when sick, and making this practice publicly acceptable will also reduce the spread of other diseases like influenza, which was minimal in 2020 as a result of social distancing and mask-wearing (Peek, 2021). Thus, making maskwearing a widely acceptable cultural practice can help reduce spread of infections even in the case of vaccine hesitancy, and can reduce the massive burdens on Indiana’s health care systems and result in healthier Hoosiers. Table 2: Comparison of total COVID-19 infections and fatalities among United States, Japan, Korea, and China

Country United States Japan Korea China

Total COVID-19 infections 40,804,998 (Sep 14, 2021) 1,644,443 (Sep 14, 2021) 275,910 (Sep 14, 2021) 123,642 (Sep 14, 2021)

Total COVID-19 fatalities 655,172 (Sep 14, 2021) 16,846 (Sep 14, 2021) 2,367 (Sep 14, 2021) 5,688 (Sep 14, 2021)

Source: WHO COVID-19 dashboard https://covid19.who.int/

POLICY CONSIDERATIONS: • • • •

Create a public outreach program in partnership with Indiana State Department of Health and county health departments to inform communities about the benefits of mask-wearing Create a dedicated webpage on the various county and local health departments’ websites that replicates this information Create policy that incentivizes mask wearing in the community when sick, not just with COVID-19 Encourage hospitals to create policy mandating mask-wearing in their facilities and to create outreach programs to facilitate this; this can save the state millions in healthcare costs in the longterm

4. VACCINATION RECORDS One of the most effective ways of ensuring the safety and well-being of Hoosiers is to not only encourage as many people to get vaccinated as soon as possible, but to also ensure that only vaccinated persons, or persons with a recent negative test result can have access to indoor spaces for dining, restaurants, concerts, etc. Proof of vaccination or a recent test would thus be needed. While the CDC has issued paper vaccination cards via the various health departments across the country, many states like California, Colorado, Louisiana, New Jersey, New York and Utah now offer portals or apps to download fully authenticated vaccination information. These can be incredibly helpful tools for restaurants, concert halls, football stadia and other venues across the state of Indiana to ensure the safety and well-being of all their attendees by having attendees provide this easy information via digital technology on their smartphones or other devices. In addition, private health care facilities and pharmacies already depend on digital records: Walmart, CVS, Walgreens and others. These reduce the risks of fake documentation, as has been seen since the use of paper vaccination cards. In the long run, this can ensure the health, well-being and safety of all Hoosiers, and reduce the stress on Indiana’s health care facilities and health care workers.

POLICY CONSIDERATIONS: •

•

Create a public portal via the ISDH Covid-19 dashboard that easily allows people to access their vaccination or recent test information. This would need to be done in partnership with public and private entities and institutions in order to ensure the safety and well-being of all Hoosiers. Potential partners would include: 1. Indiana State Department of Health (ISDH) 2. County health departments 3. Indiana state university system: Indiana University, Purdue University, Ball State University and others 4. Private universities and colleges: Notre Dame, Ivy Tech and others 5. School districts 6. Health providers like IU Health, Franciscan, Unity and others 7. Pharmacies like Walmart, Walgreens, CVS, Kroger, and others. Create a mobile app for ISDH that uses the same interface and can provide users with the same information. Currently, there are only two ways to receive a duplicate paper vaccination record: 1. Visit the location where the shot was received, or 2. Contact the local county health department via the contact information available here: https://www.in.gov/health/health-and-human-services/local-health-departmentoutreach-division/local-health-department-information/ Creating an online portal to easy access vaccination records and latest test results would therefore make Indiana communities safer and provide updated, verified and easy access for individuals.

CURRENT INDIANA INITIATIVES RELATED TO COVID-19 INDIANA DEPARTMENT OF HOMELAND SECURITY: PUBLIC ASSISTANCE GRANT PROGRAM The Indiana Department of Homeland Security is the recipient of the federal funds and administers the FEMA program to statewide applicants (sub-recipients) for infrastructure and essential services damage. The PA Program also encourages protection of these damaged facilities from future events by providing financial assistance for hazard mitigation measures during the recovery process. Reimbursements through the PA Program are subject to a cost share; 75 percent of eligible costs are reimbursed, and the remaining 25 percent is to be covered by the applicant. Under the March 13, 2020, Coronavirus (COVID-19) nationwide emergency declaration and subsequent major disaster declarations for COVID-19, state, local, tribal, and territorial (SLTT) government entities and certain private nonprofit (PNP) organizations are eligible to apply for assistance under the FEMA Public Assistance (PA) Program. On January 21, 2021, the President issued the “Memorandum to Extend Federal Support to Governors’ Use of the National Guard to Respond to COVID-19and to Increase Reimbursement and Other Assistance Provided to States”, which authorized FEMA to provide funding to PA Applicants for the safe opening and operation of eligible facilities. Such assistance “may include funding for the provision of personal protective equipment and disinfecting services and supplies.” These resources can be leveraged by county, local, tribal, and territorial governments to expand or offer various kinds of infrastructure for COVID-19 related testing, PPE provision, and vaccination sites and mobile units.

INDIANA OFFICE OF COMMUNITY AND RURAL AFFAIRS: COVID-19 RESPONSE PROGRAM On March 19, Governor Holcomb took additional actions to protect and support Hoosiers during the COVID19 outbreak with Executive Order 20-05. This order directs multiple state agencies on the expectations of providing support and protection to Hoosiers across the State. The Office of Community and Rural Affairs (OCRA) has therefore been issued the following action item: Community Development Block Grant funds may be redirected to assist with COVID-19 needs based on guidance from the United States Housing and Urban Development. COVID-19 Response Program was created to address the immediate impacts of COVID-19 on Indiana’s rural communities. Funds are derived from the State’s annual Community Development Block Grant (CDBG) allocation and guidance was provided by the U.S. Department of Housing and Urban Development (HUD) on how the funds were to be used. Beginning in April, OCRA began addressing COVID-19 impact on Indiana communities. It has since awarded 112 grants to 62 communities, totaling more than $20.9 million through the COVID-19 Response Program (Phase 1 & 2). On Dec. 7, 2020, Lt. Gov. Suzanne Crouch and OCRA announced a third phase of COVID-19 Response Program is now open for applications. For this round, eligible applicants include non-entitlement and entitlement local units of government and can apply for up to $250,000. The eligible activities include: mental health services, childcare services, public WiFi locations, food pantry or bank services, subsistence payment programs, or grants or loans to businesses to retain low-to-moderate (LMI) jobs. Phase 3 is a competitive process and communities that received an award in either previous phase may apply again. Please download a copy of the instructions for a list of all grant requirements and additional details.

This is another great resource that can be expanded and leveraged in rural communities in particular to include vaccine access. It can be used by local governments to set up vaccination outreach, clinics, and/or mobile units to ensure that rural Hoosiers are safely vaccinated and protected against the COVID-19 virus.

BACK ON TRACK INDIANA This program offered Hoosiers a phased plan to safely reopen. The program also provides a PPE directory for small businesses to make use of vendors across Indiana who provide all manner of PPE required for businesses to stay safe. The Indiana PPE Directory features Indiana companies that manufacture and distribute a variety of PPE items available for purchase. All vendors featured in the directory have been vetted by the Indiana Economic Development Corporation (IEDC) and are required to be headquartered or incorporated in Indiana, to provide free shipping to Indiana businesses, and to abide by additional requirements. The Indiana PPE Directory is organized by item and connects customers to a list of vendors that provide those specific items. Customers place and pay for orders on the vendors’ website, and each vendor handles its own shipping, payment processing and customer service. This program also has an Indiana Small Business Restart Grant, available to Hoosier entrepreneurs and small business owners with fewer than 100 employees. Through the program, eligible companies can be reimbursed for certain expenses incurred during the pandemic. Another one, the Indiana Hospitality & Entertainment Grant program is available to support Hoosier hotels, entertainment venues and promoters that have been disproportionately impacted throughout the pandemic. Through the program, eligible companies can be reimbursed up for certain expenses incurred in 2020 and 2021. The Back on Track Indiana program can be expanded to create vaccine literacy and outreach programming for communities across the state, with funding available for county and local governments, local non-profits, community block groups, certified local governments, and other entities to encourage vaccination drives across the state.

EXECUTIVE ORDER 21-21: ESTABLISHING THE GOVERNOR'S PUBLIC HEALTH COMMISSION On August 18, 2021 Governor Eric Holcomb announced the formation of a commission to examine the public health system. The 15-member panel will take a statewide look at public health departments and make recommendations to improve their structure, funding and operations. The Governor’s Public Health Commission will be co-chaired by former state Senator Luke Kenley and former Indiana State Health Commissioner Dr. Judy Monroe. Monroe now serves as chief executive officer of the CDC Foundation. Based on the recommendations of this committee, several crucial and significant policy changes can be implemented across the state’s health care system to make it more resilient to future shocks like the COVID19 pandemic. This commission must consider the dangers of the infodemic and the threat it poses to public health in the state.

EXECUTIVE ORDER 21-19: FURTHER CONTINUATION OF LIMITED PROVISIONS TO ADDRESS THE IMPACT AND SPREAD OF THE CORONAVIRUS DISEASE (COVID~19) This executive order, valid from Aug 1, 2021 to August 30, 2021, encourages all Hoosiers to get vaccinated, and take all necessary preventive measures to stem the spread of the COVID-19 virus. The order stresses that 98% of the spread is among the state’s 50% unvaccinated population, thus urging everyone to get the vaccine.

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