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States with higher vaccination rates now have markedly fewer coronavirus cases, as infections are dropping in places where most residents have been immunized and are rising in many places people have not, a Washington Post analysis has found.
States with lower vaccination also have significantly higher hospitalization rates, The Post found. Poorly vaccinated communities have not been reporting catastrophic conditions. Instead, they are usually seeing new infections holding steady or increasing without overwhelming local hospitals.
As recently as 10 days ago, vaccination rates did not predict a difference in coronavirus cases, but immunization rates have diverged, and case counts in the highly vaccinated states are dropping quickly.
Vaccination is not always even within each state, and The Post found the connection between vaccine shots and coronavirus cases at the local level comparing more than 100 counties with low vaccination rates (fewer than 20% of residents vaccinated) and more than 700 with high vaccination rates (at least 40% vaccinated).
Counties with high vaccination had low coronavirus rates that are going down. In counties where few people are vaccinated, not only are there higher case rates, but the number of cases there also is growing.
But experts worry that unvaccinated people are falling into a false sense of security as more transmissible variants can rapidly spread in areas with a high concentration of unvaccinated people who have abandoned masking and social distancing.
Nationally, 43% of eligible Americans are fully vaccinated, and the country is averaging under 16,000 new infections a day - levels not seen since the early days of stay-at-home orders in March 2020. Ten states, concentrated in the Deep South and rural West, report fewer than 35% of residents are fully immunized.
An uptick in infections in numerous states offers a preview of summer surges that could take hold "if the unvaccinated continue to behave as though they're vaccinated," said Michael Saag, an infectious-disease doctor at the University of Alabama at Birmingham. For now, risk is unevenly distributed, concentrated in communities where shots are sparse, he said.
Local public health officials fear the public is tuning out the danger as they see news reports of cratering infections and scenes of reopened bars and entertainment venues across the nation, assuming vaccinations are no longer necessary.
Missouri's Polk County - where less than a quarter of the population of roughly 30,000 is fully vaccinated - has reported nearly 90 new infections in one week, an increase after several months of decline.
Michelle Morris, the country's public health administrator, said infections are concentrated among students after the school year ended May 21 and clusters linked to Mother's Day and graduation gatherings. Immunity isn't widespread enough to naturally stop the spread.
"We are going to continue to see what we are seeing as far as our daily case count," Morris said. "Unfortunately, we are going to see increased hospitalization, and it worries me we may see additional deaths related to it as well."
A mass vaccination site in Polk County that drew as many as 400 people a day when it opened in January closed in early May after only about 100 people were showing up daily. Morris said she would reopen the site if there was demand. But like many other public health officials in low-demand communities, Polk authorities have shifted their attention to one-on-one conversations and encouraging doctors to persuade holdouts to get shots. On Thursday, her agency shared a Facebook post debunking the myth that coronavirus vaccinations make people magnetic.
A spokesman for the Missouri Hospital Association said it's premature to draw a link between low vaccination and hospitalizations in Missouri, but noted urban hospitals treat severely ill covid-19 patients from rural areas. All but four of 30 recent hospitalized covid-19 patients in Boone County live outside the county that's home to the University of Missouri, for example.
"While it isn't possible to draw a straight line between the spikes, it is likely that higher rates are resulting in higher hospitalization," Dave Dillon, the Missouri Hospital Association spokesman said. "And, given the lower capacity in rural communities to address complex covid-19 cases, these will likely materialize as increased hospitalizations in the state's metro areas or midsized communities."
Experts said boosting vaccinations is the best avenue available for limiting the damage from the more transmissible variant of the virus first identified in India and known as delta.
"Without the variants, basically the epidemic would be over in the U.S.," said Trevor Bedford, an evolutionary biologist and the Fred Hutchison Cancer Research Center in Seattle. "The previous non-variant viruses have been dying fairly rapidly."
The delta variant, which has thrown Britain's once-promising path back to normal into disarray, already accounts for 6% of new infections in the United States, officials said this week. The variant has been detected in all but two states - Hawaii and South Dakota - according to a spokeswoman for the Centers for Disease Control and Prevention.
One advantage the United States has over Britain is that health authorities here decided not to delay the second dose of the two-dose mRNA vaccines, and early evidence suggests a second shot delivers stronger protection against the delta variant than is provided by just one dose.
As variations in vaccination levels grow more stark among states - the share of eligible residents in Vermont who have received at least one dose is roughly double the share in Louisiana, Mississippi or Alabama - these disparities have gone largely unmentioned on weekly calls between governors and the White House's coronavirus task force. "Crickets," one state official said of whether governors with disappointing immunization figures were explaining their challenges and sharing best practices for boosting demand ahead of President Joe Biden's goal of getting shots to 70% of adults by July 4.
"The July 4 goal that President Biden set up is quite frankly not in our sights right now," said Keith Reed, deputy health commissioner in Oklahoma, where just 54% of adults have received at least one dose. Even though infections and hospitalizations remain under control, he said, "we know we don't have enough of the population vaccinated to ensure us against a resurgence. We know the risk is still out there."
Some public health officials have resigned themselves to the reality that many in their community will not budge on shots.
In Wyoming's Sweetwater County, population 44,000, authorities are at a loss for what else they can do to achieve herd immunity.
Sweetwater carries the unfortunate distinction of being the county with the steepest increase in infections in the state with the most new infections per capita in the country. Only a quarter of its residents are fully vaccinated, and public health officials don't see the number budging much higher.
Jean Stachon, Sweetwater County's health officer, said officials held mass clinics, brought vaccine doses to employers and churches and accept walk-ins at the public health office. They have sacrificed extra doses in a vial to vaccinate at least one person. But demand is minimal, even as the virus still looms in the community. Two people died of covid-19 in the last week. Eight emergency room patients were diagnosed with coronavirus in one night.
"As much as the general public figures covid is done, gone and over with, and they don't want to hear about it, the health department wishes the same. It's not so," Stachon said.
Kim Lionberger, director of the county board of health, said her staff is doing the best they can to provide scientific facts about the virus and the vaccines. But they are also competing with skeptical residents who prefer affirmation to information and find it from anti-vaccine doctors and questionable reports on Facebook.
"The mentality of people in Wyoming is that rugged individualism where they do their own thing and don't want people telling them what they should be doing because they are going to do what they want to do," said Lionberger.
Stachon isn't sure what she would do if a highly contagious variant tears through the community and some have already been detected. The Wyoming legislature restricted the powers of public health officials like her to put disease control measures in place.
"For me to try to say we need to go back and mask or do anything like that, I would almost think I need police protection," Stachon said. "It's just sad. You feel impotent."
There have been bright spots elsewhere in the country, including in Washington's King County, home to Seattle and not far from where the virus was first detected in the U.S., where 69% of the population was fully vaccinated and 77% had received at least one shot.
Jeffrey Duchin, health officer for Seattle and King County, said the success was a result of longtime efforts to address health disparities among racial and ethnic groups. When the vaccination program began, the county quickly tapped relationships they already forged with leaders, community groups and small businesses and placed navigators in 30 different ethnic communities.
The county also sent mobile vaccine vehicles into neighborhoods where hard-to-reach residents, such as the homebound elderly, live. He also credited trust in science.
"The bottom line is people have to want to be vaccinated, and in that sense, our community is very enlightened," Duchin said.
But there are disparities. Seventy-eight percent of Asian residents and 65% of White residents 16 or older are fully vaccinated, county statistics show. But just half of Black and Latino residents have completed the full course. The county projects that those communities won't reach the 70% landmark until Sept. 7 and Sept. 2, respectively.
Access is the easiest obstacle to overcome, Duchin said. More difficult are fears among some people about missing work if they encounter side effects from the vaccine. Others have been poisoned by misinformation, he said.
"There are early adopters and people who are not early adopters," Duchin said. "I think it's wrong to assume that everyone who is not currently vaccinated is not interested in being vaccinated and will not be vaccinated in the future."
The broader slowdown in vaccinations may be a sign that the United States cannot vaccinate its way to safety from new virus variants, said Neha Agarwal, associate director of diagnostics at PATH, a global health equity nonprofit.
"We're beginning to reach a saturation point in terms of the population that's willing to be vaccinated," she said.
What's needed is long-term investments in testing and surveillance, similar to those made in several Southeast Asian countries after the 2009 H1N1 flu pandemic, she said. Germany, too, is betting on expanded testing as a way to safely permit people to resume normal activities. In the U.S., meanwhile, testing has fallen off dramatically, and public testing sites have closed throughout the country.
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The Washington Post's Joel Achenbach contributed to this report.