Vaccine Availability and Access with Missoula Public Health

The federal process for approving and recommending seasonal respiratory vaccines deviated from the typical schedule this year. That led to confusion about who is eligible for Covid vaccines and delayed shipping and distribution of the shots.

This week, Jeanna Miller and Sara Heineman from Missoula Public Health joined the commissioners to unpack how all of this happened and how the Immunization Clinic at MPH is here to help. They also discuss what they learned from the health department’s recent countywide vaccine access and barrier report. 

Thank you to Missoula's Community Media Resource for podcast recording support!

Transcript

Juanita Vero: [00:00:10] Welcome back to the agenda with your Missoula County Commissioners. I'm Juanita Vero and I'm here with my fellow Commissioner Josh Slotnick. Commissioner Strohmeyer is out this week. We're here today to welcome Jeanna Miller, chief health officer at Missoula Public Health. And she's joined by Sara Heineman, director of health services at Missoula Public Health. And they're here today to talk about vaccine availability and other public health services. Welcome.

Sara Heineman: [00:00:36] Thank you.

Jeanna Miller: [00:00:37] Thanks. Happy to be here.

Josh Slotnick: [00:00:38] Yeah. Thanks a lot, guys, for for coming. I want to throw a curveball at him right away. Okay. Easy though. Super easy, super easy one. So we're going to talk about vaccinations. But before we dive in, I just wanted to find out from you guys. How did you find yourselves in the world of public health? I mean, I can imagine when you were when you were 14 years old, you're like, I really want to be a public health person. That's my goal. And look at you. Both of you now have lots of authority, and you really play very effectual roles in the general health of people in our county. How did you find yourself in these positions?

Jeanna Miller: [00:01:09] Oh, yeah, I.

Juanita Vero: [00:01:11] This is Jeanna.

Jeanna Miller: [00:01:11] Speaking. Yeah. I'm sorry, this is Jeanna Miller. I think that I landed in public health at random somewhat and and then fell in love with it. I got my undergraduate degree in environmental health and water quality technology, and then I kind of went rogue and applied for jobs all over the place, including Missoula, and moved from Havre to Missoula and landed at the health department when I was very young, and then went to the University of Montana for my master's degree, and found out that the broad field of public health is pretty much everything I care about, all wrapped into one field. I mean, it's beautiful. It's things that I have valued and have been really passionate about, just in general and and socially and scientifically for a long time. And so I'll stay forever. Just always will always be what I do.

Josh Slotnick: [00:01:55] We are very thankful.

Juanita Vero: [00:01:56] Oh, yes. Absolutely.

Josh Slotnick: [00:01:58] Though you will outlast me. I'm thankful anyway. Sara.

Sara Heineman: [00:02:02] Gosh, yes, I did a senior clinical rotation from nursing school at the public health department and was to implement HIPAA way back when. That's a whole nother topic. And then when I was working at the hospital as a nurse, there was an opening in the immunization clinic at the health department. So I did that as a public health nurse and then tried out home visiting. And then I became a nurse practitioner and worked in the world of urgent care and primary care. And I really missed the idea of prevention, preventative care, and wanted to make more of that upstream difference in my community by being able to focus on preventative work, because our medical society really doesn't have that focus.

Josh Slotnick: [00:02:45] So for both of you, would it be fair to say this is a bit of a calling?

Sara Heineman: [00:02:48] I would say yes.

Jeanna Miller: [00:02:49] I would say yes. I love my job. I think it's a dream job. I agree. We get to show up every day and just try to make the place better. That's pretty cool, man.

Juanita Vero: [00:02:57] We gotta ask this question of all our guests. I'm embarrassed that we haven't done that. Thank you both so much for that.

Josh Slotnick: [00:03:05] So there's been a lot of talk out there in the world and the national world about vaccines and the availability of vaccines, and what insurance won't cover and will cover and what's needed and what isn't. Can we talk a bit about Covid because we're heading into winter? What what is available? Who can who can get a Covid vaccine? And why do you think there is so much confusion?

Jeanna Miller: [00:03:24] I will start with just the short statement that to explain what's going on with the Covid vaccine this year, we really have to dive into how vaccines are reviewed and tested and approved in the United States in the first place. And Sara is excellent at telling the story.

Josh Slotnick: [00:03:38] Sara, tell us, tell us that story.

Sara Heineman: [00:03:41] Well, I will try. Well, there was a lot of confusion this year about the Covid vaccine because it didn't follow the normal processes. So I'll just start by saying that anyone six months and older can get their Covid vaccine. It is with shared clinical decision making, which I'll explain a little later, but basically means you just have to have a conversation with the medical provider.

Josh Slotnick: [00:03:59] And what are the normal processes when you do your explanation?

Sara Heineman: [00:04:02] So there there's a lot that goes into making vaccine recommendations. If you're thinking about vaccine development and you go back even further to that, you go through the FDA and all of the different preclinical trial clinical trial steps of of safety and effectiveness. And it can take years to go through those processes to a licensed product. And then the FDA has their prescribing information that describes what the product and how it should be used, who it's for. And then the Advisory Committee on Immunization Practices, which is a committee through the centers for Disease Control, CDC would get together three times a year, and they would review all of the the data, the safety data, the efficacy data. And then they would they would make recommendations about those vaccines. And so where we went awry this year was earlier this spring when the ACIP committee was all terminated. Is that the Advisory Committee for Immunization Practices? So that committee was terminated by the current Health and Human Services Director, Robert Kennedy Jr. And he reappointed some of his own people who have some differing ideas on vaccines. That committee didn't meet on their scheduled timeline in the spring because of those changes that happened. And so the FDA, interestingly, went ahead and met and made their own recommendations internally for this year's seasonal flu vaccine, which also created some confusion. Usually we're part of the World Health Organization. You know, all these different countries and groups come together and they look at what's going on in the southern hemisphere for the next year, and they they collaboratively come up with what the the influenza strains should be included for this year's seasonal flu vaccine. And that didn't happen this year either. So that. Yes. So that that also started out with creating some confusion with Covid.

Sara Heineman: [00:05:49] The FDA then went ahead and they made their own recommendations for the Covid vaccine, and they changed that. And they said that anyone 65 years and older, or someone who has a compromised health system should get the Covid vaccine. And that's different than how we've been treating the Covid vaccine over the last few years. And that's because the ACIP committee didn't meet, and there wasn't that robust review of the data to have those recommendations be made. And then as they added a few more members to that, they did have a meeting in in late September, which it's already the respiratory season, right? Clinics are gearing up to give their flu and Covid vaccines for for the fall and usually September and October. And so the ACIP committee met at the end of September. They had a tie vote of their committee that said anyone six months and older could get the vaccine. And then the committee chair broke the tie with shared clinical decision making. So meaning that your medical provider, registered nurse or pharmacist, you have that conversation. You discuss the risks and benefits of the vaccine versus the disease, and then you can get that vaccine. Well, once the ACIP makes that decision, the CDC director has to adopt that or endorse it. And that was also delayed. So it took another couple of weeks for the interim CDC director to endorse and approve that recommendation. So in the meantime, you had these other nationally recognized organizations like the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and then the American College of Family Physicians come out and make their own recommendations, and they were all in alignment.

Josh Slotnick: [00:07:23] And so all of those organizations were in alignment.

Sara Heineman: [00:07:25] Absolutely, yes. And you saw a lot of other states standing up and either setting up statewide collaborations. So there was the Pacific Northwest statewide collaboration. There's a northeast one. There's some other states, and they were coming up with their own recommendations for those states together to say, we're going to follow this information so that people could start to get the vaccine out.

Josh Slotnick: [00:07:45] Now, with all those different organizations. At least you said the medical ones were in alignment. But how about those ones that were designed around geography? Did we have alignment there too, or did we see differences?

Sara Heineman: [00:07:54] The ones that joined together definitely were aligned are aligned. Yes. So there are.

Josh Slotnick: [00:07:59] So it's not like there were 15 different opinions out there. It sounds kind of like.

Sara Heineman: [00:08:03] They were they were pretty they were pretty pretty aligned with what the Acog, AAP, and the American family physician said.

Juanita Vero: [00:08:10] So what's that mean for where we are now? Or what does it mean then for well, can Josh go in and get a Covid.

Sara Heineman: [00:08:16] Yes. So once.

Juanita Vero: [00:08:17] Shot, if you.

Josh Slotnick: [00:08:18] And are you thinking I'm over 60?

Juanita Vero: [00:08:19] Oh, I was just oh so sorry...So sorry.

Sara Heineman: [00:08:22] Any anybody six months and older can get their Covid vaccine.

Juanita Vero: [00:08:25] And how much does it cost?

Josh Slotnick: [00:08:26] I actually got me.

Sara Heineman: [00:08:27] Their insurance is supposed to.

Juanita Vero: [00:08:28] Pay for okay if you don't have insurance.

Sara Heineman: [00:08:30] Um, well, if you come to the health department, you'd probably qualify for a no cost vaccine with a sliding fee scale for the administration fee.

Josh Slotnick: [00:08:38] So let's just drill down on that a little bit, because that sounds like some really important public information. Yes, a person can go to the health department and get a vaccination, even if they don't have insurance. Correct. Do they have to set up an appointment?

Sara Heineman: [00:08:49] You can if that works for you.

Josh Slotnick: [00:08:51] How would a person go about doing that?

Sara Heineman: [00:08:53] You call (406) 258-3363.

Josh Slotnick: [00:08:56] Is there an online version or do you just do it by phone?

Sara Heineman: [00:08:58] Just do it by phone.

Josh Slotnick: [00:08:59] Awesome.

Juanita Vero: [00:08:59] And then you said sliding fee scale. But like what are the numbers. Because we've heard some crazy numbers on what certain drugs are called are costing. Yeah. I mean, it's kind of insane. So what are the numbers?

Josh Slotnick: [00:09:10] Are we talking like $10 to 50 or is it 10 to 1000?

Sara Heineman: [00:09:13] As a local health department, as a vaccine for children provider, we also have vaccine for adults. So that is federally subsidized vaccine that comes through the state health department to local health departments. So we don't have to pay for that vaccine. We can charge a minimal admin fee to like poke you, poke you vaccine. Right. And that's the piece that we can slide. And so depending on somebody's income, we don't ask for proof or anything like that. You just fill out the little form and then it will slide down to zero depending on that information. So it's really easy to do that. And then we do appointments on Wednesdays and then Monday, Tuesday, Thursday, Friday it's walk in at your own convenience.

Josh Slotnick: [00:09:49] So you don't even have to make an appointment if you want. Yeah that's great.

Jeanna Miller: [00:09:52] It's not just flu and Covid. Yeah. You know, we've been talking to a lot of people about vaccines these last couple of months. And that's something that I think surprised some folks is that we have all routine vaccines available at the health department.

Josh Slotnick: [00:10:03] Oh that's great.

Juanita Vero: [00:10:05] Are you current with your shingles shots?

Josh Slotnick: [00:10:06] I do need to get shingles a shingles shot. I don't need to get shingles. I just need to get the shot. Rather not get the shingles. Just.

Sara Heineman: [00:10:13] To see us.

Josh Slotnick: [00:10:13] Yeah. So are the same rules apply? Like, you know, the pharmacy in Albertson's? They do.

Sara Heineman: [00:10:18] Yeah. Pharmacies are a little, little bit different. So each state has their own state laws about how pharmacies can practice with immunizations. And so all of this goes back to that ACIp committee vote. Right. And so the Advisory Committee on Immunization Practices and the CDC endorsement of that is tied to the Affordable Care Act and whether the insurances will cover that as a preventative service. So that's where all of the insurance payers, we're starting to step forward and say we'll cover Covid vaccine for this season because because that was being so delayed in the recommendations coming out. The other thing that is tied to that committee that's super important are the vaccine for children program and then folks that are on Medicaid. So if the advisory committee didn't vote for that, for example, then that would not be available through the vaccine for children program and Medicaid wouldn't cover it. That vote was critical, and that endorsement by the CDC director was critical to make sure that that vaccine flows through the normal channels. So with that, insurance payers are covering it because that's what they're supposed to do through the Affordable Care Act for as long as that continues to cover preventative services. And so then with pharmacies, they were on hold with all of this because the Prep act, which was a leftover emergency act during the pandemic, which allowed all pharmacists to vaccinate down to age three for flu and Covid vaccines, regardless of state laws, was also put on hold because of this, because that was tied specific to those ACIp recommendations. So once that CDC endorsement was opened up, then that National Prep Act allowed pharmacists to go back and do that. In Montana, we have Montana Code annotated in some rules that talk about how pharmacists can vaccinate, and they have to have been immunized. Certified pharmacist so not all pharmacists offer vaccines.

Josh Slotnick: [00:12:08] Who does that certification.

Sara Heineman: [00:12:09] Through the state I believe. Yep. And then they kind of have two forks that they can take. One they can set up without a collaborative practice agreement. Collaborative practice agreement is something that's with a with another prescriber. So it's kind of like a standing order or an agreement that says you are collaborating with me as a prescribing provider, that you can give these vaccines. So without one of those, pharmacists can give flu shots in general to ages 12 and up. Pneumonia, Tdap, which is tetanus, diphtheria and pertussis to those that are 18 and older and then shingles. So they have a limited scope of practice in in normal times without a collaborative practice agreement with the collaborative practice agreement, they can give vaccines identified within that agreement down to age seven. So it gives them a broader scope of practice. And then the Prep act right now, kind of it allows them to go down to age three for flu and Covid vaccines.

Josh Slotnick: [00:13:05] So earlier you mentioned the seasonal flu and some of the it sounded like some of the recommendations on what that vaccine should be for each winter weren't done in the typical pattern. Correct. So does that make you feel differently about this year's seasonal flu vaccine?

Sara Heineman: [00:13:21] No, I think it's still very important to get vaccinated. Vaccine is is one of the factors that's going to help prevent you from getting influenza. So influenza is not the stomach flu. It's not a 24 hour, you know, vomiting diarrhea, kind of flu. We use those words interchangeably. And this is a respiratory disease. And so people get very very ill where they have fever headache sore throat, cough congestion, body aches, chills. And they're usually out for a week to ten days with with this respiratory illness it's quite contagious. And so we get the flu shot to help prevent that. And then ideally you would wash your hands, stay home when you're sick, avoiding other people when they're sick. And that will help you get through this respiratory season.

Josh Slotnick: [00:14:03] Great. If I understand it right. You all went through kind of a countywide vaccination assessment. We did describe what that is.

Sara Heineman: [00:14:09] Yeah, that's very cool. We did a vaccine access and barrier.

Juanita Vero: [00:14:14] Is this routine. Do we always do. No.

Sara Heineman: [00:14:16] Oh no. We had some funding from our Covid days that we were able to put towards this. And so we hired a third party research group. This spring feels so long ago, but it really was just this spring. Yeah. Um, it was in March and April. So we contracted with Clarus Research and they had ties to the University of Montana, and we asked them to help us conduct a community wide vaccine assessment that would look at Missoula County.

Jeanna Miller: [00:14:43] Can I just add a thing? While you're kind of gearing up to talk about the details, I think that one of the things that we contend with here in Montana is the fact that this data is not readily available, that it's really hard to get. So it's not routine for us to do this assessment. And unfortunately, it's not data that we can easily access without investing a whole lot of funds. And these were one time funds well invested so that we could collect community or county specific data and adjust practices. And it was we had a big ask of this, um, this research group, and they were phenomenal. We had a short turnaround because the the funds had an expiration date. And so it was a bit of a scramble. And boy, they certainly they delivered.

Josh Slotnick: [00:15:27] It was amazing what what the ask was what did you ask them to go look at.

Sara Heineman: [00:15:30] So what we ended up doing was a point in time survey looking at something that they could fill out online, or they could ask for a paper copy to be mailed out. And of the people who did that, they could volunteer if they wanted to participate in a, in an interview. And so this is considered a non-experimental cross-sectional type of a research project. And, and our research coordinators stratified random sampling weighted for an oversampling in the rural areas, meaning we're trying to get more of our rural community members to respond so that they have representation. And they used publicly accessible property data from the Missoula City County Property Information System. So we we sent out a little postcard to over 3000 households, both single family and multifamily units that represent all 80 census blocks throughout Missoula County. And they were randomly selected. And then we sent a reminder postcard. And then we ended up doing some more work in our rural communities, where we hung up fliers and put just additional stacks of postcards at the grocery store, the post office, and trying to get more people to respond. So of that, they had 388 surveys came back 10%.

Josh Slotnick: [00:16:39] Which was great, really great.

Sara Heineman: [00:16:40] They were very happy with that number of that. Then they looked at the I think there was 200, 204 people volunteered to be part of the qualitative interview. And so they selected ten.

Josh Slotnick: [00:16:50] That's a high number.

Juanita Vero: [00:16:51] For.

Josh Slotnick: [00:16:51] That.

Sara Heineman: [00:16:51] So they interviewed ten people kind of across the board with however, they answered the survey questions so that they had a diverse response from those folks. And they got some very rich information. The questions that we asked, there's three, three different questions with some subquestions. And the first one was, are Missoula County residents getting vaccinated? If so, where are they coming to Missoula Public Health or where else are they going? And then the second question is what are the barriers to getting vaccinated at Missoula public Health or any place else? And then what could we do to help build awareness or improve access to vaccines in the public. And then the third question was what are Missoula County residents concerns related to vaccines? And then what could we, as Missoula public Health, do to address those concerns? With the first question, are people getting vaccinated? Yes. Over 90% of the people that responded said they had received a vaccine in the last two years. Most adults use the pharmacy or their health care provider, and for kids, it was their health care provider.

Juanita Vero: [00:17:53] Does it say what kind of vaccine or just their vaccine?

Sara Heineman: [00:17:55] Any any vaccine? We just wanted to know if people had received a vaccine. That was the hardest part, was drilling down the questions and trying to limit it with not asking so many questions. I had so many questions.

Josh Slotnick: [00:18:07] Yeah, I'm sure.

Sara Heineman: [00:18:09] I didn't have the time or the money to ask them all. So with the second question, what are the barriers to getting vaccinated at Missoula Public Health or elsewhere, and what could we do to improve that? It's interesting because 59% reported ever receiving a vaccine from Missoula Public Health, and my guess is that a lot of that was during Covid, so they probably came to like Lucky's or one of those places during Covid, but only 11% of those people had come to us in the last two years for a vaccine. So that aligned with what we had been feeling and seeing anecdotally in our own clinic numbers, just that decrease in number seeking services. So, interestingly, more than 40% of the people who had not come to Missoula Public Health said because they didn't know we offered vaccine services. So that's definitely something that we're working on as an as an outcome. For those that did seek services at Missoula public Health, one of the most common reasons was their trust in Missoula public health.

Josh Slotnick: [00:19:05] All right, nice job.

Jeanna Miller: [00:19:06] Yeah. And so I think that that second question and the results that we got have really driven a lot of what we've done after the survey.

Juanita Vero: [00:19:14] So anything that surprised you guys.

Jeanna Miller: [00:19:16] I'm I'm constantly surprised. I mean, look at my face. I'm always surprised. Um, but one of the things that we learned in the survey that surprised me was that people didn't know that we offered vaccines. [00:19:27] The other thing we heard in some of our discussions and outreach afterward is that folks believed, perhaps, that getting a vaccination at the health department would somehow take away a vaccine opportunity for someone else, as if we had, like a limited stock. Not true at all. Health department vaccination clinic is for everyone all the time. And then the other thing always that just sticks with me is that of the people who did not get vaccinated at the health department, the majority of them said if they would have known that getting vaccinated at the health department supports the health department, they would have made that decision. [00:20:00] So it's easy. You know, you're at the grocery store and they have a pharmacy, and you stop in and get your flu and Covid or whatever it might be.

Juanita Vero: [00:20:06] And then they give you a coupon to go shopping.

Jeanna Miller: [00:20:08] It's true. It's true. And and I think that what we offer at the health department is such a critical and amazing community service. We are staffed with trained nurses who will discuss all kinds of things with you, including other health department services that could really improve your life? Yep. And just like any other public service, it's like adopting an animal from Missoula. Animal control supports the health department. Getting your immunizations at our clinic supports the health department. There's just a real opportunity to sort of shop local. Shop small.

Josh Slotnick: [00:20:37] Great, great.

Sara Heineman: [00:20:38] So a couple of other things we learned. One of the third question that asked about Missoula County.

Josh Slotnick: [00:20:43] Attitudes.

Sara Heineman: [00:20:44] Concerns related to vaccines, and more than 80% agree or strongly agree with statements about vaccine effectiveness in protecting their personal health, the health of their children and the community. So overall, there's very low vaccine hesitancy in Missoula County, which we were very happy to hear of. That was interesting. So of the 52% of the households who'd never used Missoula public health for vaccines and had not received a vaccine anyplace else in the last two years, said that it's because there's a disagreement in their household on whether vaccines are necessary. And when they did the interviews, the qualitative interviews of this. It really came down to, I think more specifically Covid as its own separate factor. Like there's so much to unpack with Covid vaccine, whereas the other routine vaccines, maybe there's more ingredients on. But Covid was identified as as a kind of a subchapter in that disagreement. But you might have a parent and a stepparent or another parent, and they have differing opinions about vaccination for their kids. And so then, you know, their kids until they're older, maybe aren't getting vaccinated until they can make that decision on their own. So that was that was really interesting. And then the a couple of other things that came out of that that were also looking to make a change with there was a percentage, I think it was 24% that said, we're not in network with their insurance. We know that we're not contracted with UnitedHealthCare and Tricare because we've had it's just been hard for us to get those contracts in place. I'm hoping we're breaking through some of our own barriers with that, and we'll be able to do that starting with UnitedHealth. So I know that would be helpful to a lot of people because there are this community, a lot of people have both of those insurances, so it would be great if we could serve them.

Josh Slotnick: [00:22:25] On this last. On the third question around I was I was calling it attitudes or concerns or was there anything in there that was surprising to you?

Sara Heineman: [00:22:32] Well, I think it was reassuring that more than 80% of the people don't have vaccine hesitancy. And so that made me feel really good. Earlier this spring, going into to this year, with the change in the administration, with the changes at the CDC that our community overall believes in vaccines.

Josh Slotnick: [00:22:50] Is it possible for you all to get data on actual vaccinations across our community? Like X, percentage of people of adults have been vaccinated for Covid in this year or that, I don't know, is that possible?

Jeanna Miller: [00:23:02] It's really hard.

Josh Slotnick: [00:23:03] Because there's so many delivery spots, right? If you go to your provider or a pharmacy or the health department.

Jeanna Miller: [00:23:09] Yeah. And and the state has not really set up a robust system for collecting and tracking that data, not even within the school system where certain immunizations are required. Montana is one of those states that doesn't compile that data. There's been some recent changes at the legislature that's made it even harder to fully understand our statewide student population. So, you know, we work closely with various organizations in town, including our schools, and then supplement with something like this really targeted assessment to get a pretty good idea of the cross section here. But I would say it's nearly impossible to understand, especially per vaccine, kind of what our immunity rates are. And that's unfortunate, because community immunity is a studied and evidence based principle. And for different diseases, you have kind of different targets that you want to get to, to where you don't have to worry about a very big community outbreak.

Josh Slotnick: [00:24:00] Are there outbreaks of specific diseases going into winter you guys are actively concerned about?

Sara Heineman: [00:24:05] Well, definitely. Our infectious disease team is monitoring reportable illnesses, which include influenza and Covid.

Juanita Vero: [00:24:14] What's the long running measles? No no no no no. It's like it's been going on for.

Sara Heineman: [00:24:19] Pertussis.

Juanita Vero: [00:24:20] 18 months or whatever. Nine months. Slow moving outbreak that we're in the middle of.

Josh Slotnick: [00:24:25] I thought it was measles?

Sara Heineman: [00:24:26] Group A.

Juanita Vero: [00:24:27] Strep. Yes.

Josh Slotnick: [00:24:28] Oh that's strep group A strep....That's the wound. Strep wound. That's the wound. Strep.

Jeanna Miller: [00:24:33] But the strep. That does bring up a really good point and might answer your question in a more general way about, you know, what kind of diseases are sort of on our radar this respiratory season or in general. I think that public health does such a good job collecting reports of infectious diseases and having conversations and talking to those and investigating what the source of that disease could have been, and kind of putting a ring around it and protecting our community in that way without it ever being known. So, you know, there's communicable disease in our community all the time, every day. And the fact that public health folks are every day of the week taking those calls and trying to figure out the source and how to prevent further spread is something that people don't always know about, because that's the point. We don't. We don't want there to be a gigantic outbreak that really increases the burden of disease in our community, and takes up hospital beds and takes up provider time. And, you know, it's it's something that we certainly want to avoid in public health is working on every day.

Juanita Vero: [00:25:32] Wash your hands, folks.

Jeanna Miller: [00:25:33] Wash, wash your hands and certainly stay home when you're sick.

Josh Slotnick: [00:25:36] It's more part of the great invisible work that local government does. We just assume things work out and in part around these types of diseases. They work out because you all are doing this type of labor.

Jeanna Miller: [00:25:47] Which is the positive side. And maybe this could be a go back. I'm not sure to something we talked about earlier, but I think awareness is something that we're really trying to raise right now. And we talked about some of the delays with the ACIp committee meeting and making those decisions, and then a somewhat delayed sort of adoption or endorsement by CDC and the mayhem that that actually caused in the delivery system. That was maybe step one. So there was another scheduled meeting of the ACIp to look further at different vaccines and different schedules for different age Americans, and that meeting was canceled or postponed due to the shutdown. So in terms of public health practitioners who are really about disease prevention and trusting these vaccines, who have gotten us so far in our history in terms of reducing disease and improving life quality and length of life, we certainly have an eye on what's coming next. Because while we're happy to hear that not many folks in Missoula have specific concerns or really strong vaccine hesitancy, there's an entire national conversation, and it could be about, for example, the childhood immunization schedule. As we all know, there's all kinds of ways that we can protect young people against preventable diseases, and we want to see those protected. And so when the federal government is back at work and there's another scheduled meeting of the ACIP. Sara and I are certainly going to be watching it and trying to inform folks in our community about what's being discussed and how you can have your voice heard.

Juanita Vero: [00:27:17] Do we make any changes based on what you guys learned with the assessment?

Jeanna Miller: [00:27:21] Yeah, we certainly did. You know, the the point that I brought up about people not knowing that the health department provided all routine vaccines, and if they would have, they would have made a choice to use our services has led us to sort of an outreach and advertising campaign, the likes of which our clinic has never seen. Sara has some great ideas about where we can be advertising to meet certain populations, kind of where they are. We have billboards, we have some magazine ads we're working on, um, hopefully getting some of those, you know, you see the bathroom stall signs.

Josh Slotnick: [00:27:51] Yeah.

Jeanna Miller: [00:27:52] I don't think I'm. Advertisement consumer until I'm in a public bathroom.

Josh Slotnick: [00:27:56] Yeah, exactly.

Jeanna Miller: [00:27:58] How about.

Josh Slotnick: [00:27:58] That? Outside of the bus?

Sara Heineman: [00:28:00] The side of the bus?

Josh Slotnick: [00:28:01] Yeah. I think especially with folks who are riding the bus.Yeah.

Jeanna Miller: [00:28:04] We've also visited all the community council's. Not yet, but we're getting close to having all of them visited to just talk about the assessment and let them know what we have to offer.

Josh Slotnick: [00:28:12] I think they'll really be interested in this assessment.

Sara Heineman: [00:28:15] They've been really great to visit so far. I've made it through about half of them and and they've had some really great ideas about their own specific community, about where to hold a clinic, where else we might be missing for advertising, some trusted community partners who could be those messengers for us. So that's been great.

Josh Slotnick: [00:28:33] Well, if we were to, just as we end, come to a close here, look back on what I'd asked you guys just to consider public health in general. What's something you really want people to know about what public health is?

Jeanna Miller: [00:28:43] I think something that I want everyone to know and really consider and probably internalize is that we can't do public health alone. Yeah, you can't really opt out of public health. It's what we as a society do together. It's the things that we have agreed will create.

Josh Slotnick: [00:29:00] It's kind of like what happens when somebody chooses to opt out of traffic laws, We gotta all do it.

Jeanna Miller: [00:29:07] We've got some basic, common agreements that we, you know, when we support them and when we fund them and when we all agree and move in that direction. We have amazing capacity to improve everybody's health. And it's public because it's not health care. This is public health. And the possibilities really are endless. If we could get everybody in the boat.

Josh Slotnick: [00:29:26] Oh, that's a good one, Jeanna.

Juanita Vero: [00:29:28] And well, Sara, you spent some time like all over the world, working in some really unique places. Like what? What do you see when that community buy in? Isn't there whether people don't have the resources to buy in or they choose not to buy in.

Sara Heineman: [00:29:43] Things are a lot harder, right? You have more people who are sick. You have more people who are unable to work. You have more people utilizing the medical system. Costs are more expensive for all of those reasons. When you think about prevention, it's an upfront investment and it's an investment not only in yourself or your family, but in your community. And it's something that I would would love to see a shift in our society that we embrace preventative medicine.

Jeanna Miller: [00:30:09] And one thing Sara has taught me in her work in developing countries is that actually, oftentimes their system for vaccine delivery is stronger than ours. And so while while there might be a much smaller GDP and in general, a larger percentage of the population living certainly below whatever poverty line has been established, there are rates of preventable diseases is lower than it is in the United States because of the strong uptake and strong delivery system for vaccines.

Josh Slotnick: [00:30:39] Are there lessons there we could learn?

Jeanna Miller: [00:30:41] For every dollar you spend in prevention, which includes vaccines, you get about 7 or $8 back. And that was a...

Juanita Vero: [00:30:48] That's a good.

Jeanna Miller: [00:30:49] Start. That was an economic study from about ten years ago. And so I don't know how inflation impacts that.

Josh Slotnick: [00:30:54] But wow that's a good one.

Sara Heineman: [00:30:56] It's worth the investment for sure.

Josh Slotnick: [00:30:58] Well do you is there anything else around vaccines or public health, you want to make sure you get the chance to say.

Sara Heineman: [00:31:05] Yeah. So every fall we do an off site clinic season. So we try to hit all of our rural communities. We're out and about just trying to make it easier for people to access flu and Covid vaccines. And compared to last year, it felt like we were seeing more people, like there was more interest in our services. And so comparing last year's time to this year's time, we still did 19 offsite clinics. So that.

Josh Slotnick: [00:31:27] 19! Fantastic.

Sara Heineman: [00:31:29] It's great. And we did 19 last year, so we didn't add any more clinics specifically. But this year we saw 783 people so far, and we gave over 1200 vaccines. Last year we saw 524 people and we gave 884 vaccines.

Juanita Vero: [00:31:45] So that's the scarcity mindset.

Josh Slotnick: [00:31:48] Yeah.

Juanita Vero: [00:31:48] Yeah.

Sara Heineman: [00:31:49] And that very well may be part of it. You know when you have supply and demand and people are like, oh my gosh, I can't I.

Josh Slotnick: [00:31:55] Can't get this.

Sara Heineman: [00:31:56] Well I can't. So I better get it while I can. Yeah I've heard that question come from people. I also hope that it's just it's a collective response in wanting to protect yourself and your family from getting sick.

Juanita Vero: [00:32:08] When did these clinics happen?

Sara Heineman: [00:32:10] Through most of October.

Juanita Vero: [00:32:12] Ah, okay.

Josh Slotnick: [00:32:13] Vaccines of the new Birkin bag.

Juanita Vero: [00:32:15] Yeah, I mean, I, I felt that way. a Lot of people were getting sick in September and early October and I was like, oh my God, I need to get my flu shot. 

Josh Slotnick: [00:32:26] And I was aatching the Federal government and the ACIp not meeting and a whole bunch of people getting terminated. It did feel like, oh man, this is going to end. If I want one of these, I better get on it before it's impossible.

Sara Heineman: [00:32:37] And there are some valid concern to that. And when the ACIp meets again, um, they are looking at the childhood immunization schedule.

Juanita Vero: [00:32:46] When's that meeting?

Sara Heineman: [00:32:47] It's to be determined with the shutdown or.

Juanita Vero: [00:32:50] Oh. No idea.

Sara Heineman: [00:32:51] It's on hold right now. They were supposed to meet again in October, but it's definitely something that we're concerned about. And if they start to change that schedule and those recommendations again, that how everything is tied to it with the vaccine for children program and whether insurance payers will and can pay for it. So all of that is is to be determined.

Jeanna Miller: [00:33:11] Right. And the and the concerns that we will have will be immediate, of course. But remember that vaccination is a long game. And so while in the, you know, months following some sort of change, however small or radical to a childhood vaccine schedule that's been sort of institutionalized for decades, we don't see those impacts for the next six months or maybe even the next year. But when we start seeing outbreaks in our schools or a whole bunch of our young people really, really debilitated by diseases that are preventable, you know that that could happen years down the road and the collective burden is the risk is significant. These are contagious diseases.

Josh Slotnick: [00:33:49] Wow. All right. We're going to hit you with the you guys with the last our last fun question. So in the recent past, have you run across some nugget of culture. You feel like that really stuck with me, and I'd love to repeat that. Whether it was something you heard in a podcast or read in a book, or saw on a Netflix show, or ran into in conversation, just something that you thought, man, that was really interesting. I'm going to brain's going to hold on to that for a minute.

Jeanna Miller: [00:34:11] I get so excited to talk about this. Um, when you said nugget of culture.

Jeanna Miller: [00:34:17] Yeah, I just finished a book by John Green called Everything Is Tuberculosis.

Josh Slotnick: [00:34:23] Oh, wow. Of course you did, right.

Jeanna Miller: [00:34:25] I know. And a dramatic title.

Jeanna Miller: [00:34:27] But it is a.

Josh Slotnick: [00:34:27] Really dramatic.

Jeanna Miller: [00:34:28] Title...Everything is tuberculosis.

Josh Slotnick: [00:34:30] What is it? What is that? What does he mean by that statement?

Jeanna Miller: [00:34:32] It is a cultural nugget for sure, because it talks about the way tuberculosis was first thought of before the germ theory was even known to man. All the way to what? What that looked like in developing the United States.

Juanita Vero: [00:34:47] They thought it was.

Jeanna Miller: [00:34:48] The cowboy hat is tuberculosis.

Juanita Vero: [00:34:50] Wow.

Jeanna Miller: [00:34:50] And and that's important to us. Who who grew up on on a ranch. The cowboy hat is influenced by tuberculosis. Yeah, you have to read it. Um, it really is about the complete misunderstanding about tuberculosis and what it is and what caused it. But a lot of times, our more populated areas on the east side, like a...

Juanita Vero: [00:35:09] ...Character flaw, if you if you get it, you deserve it because you.

Jeanna Miller: [00:35:12] ..Need a dry air.

Juanita Vero: [00:35:14] That's how my great grandmother came here, right?

Josh Slotnick: [00:35:16] There you go.

Jeanna Miller: [00:35:16] And so there was a hat maker on the eastern side of the United States who had some really avant garde and cool headwear going on, and he got tuberculosis, and he had to move west. And then he designed something for vaqueros and cowboys.

Juanita Vero: [00:35:29] Oh. All right. That is great.

Josh Slotnick: [00:35:32] Love the connections.

Jeanna Miller: [00:35:33] It's a great nook.

Josh Slotnick: [00:35:34] Cool. Everything is tuberculosis. That's a good one.

Sara Heineman: [00:35:41] I just said I can't compete with that. It's too great of an example. I'm like, I'm not that interesting.

Juanita Vero: [00:35:46] Everything is public health.

Jeanna Miller: [00:35:48] Everything is public health.

Josh Slotnick: [00:35:49] Everything is public health.

Jeanna Miller: [00:35:51] Yeah. I think what you're learning is Sara and I are just at work all the time.

Josh Slotnick: [00:35:55] It seems like that. Yeah. Yeah.

Juanita Vero: [00:35:56] Well, what you what gets you through your grind? Like you guys deal with some really difficult stuff.

Josh Slotnick: [00:36:01] The stakes are high.

Sara Heineman: [00:36:03] Yeah. I mean, I just I need to connect with the outdoors, so that's how I deal with it.

Josh Slotnick: [00:36:08] What does that look like?

Juanita Vero: [00:36:09] Touch grass. Touch so hip.

Jeanna Miller: [00:36:11] Yeah, that's. That's more than touch grass for her. She travels the world taking wildlife photos.

Josh Slotnick: [00:36:16] There you go. Looking for that? You do?

Sara Heineman: [00:36:18] Yes, yes.

Josh Slotnick: [00:36:19] Where do you like to go or where have you been recently? That was wonderful.

Sara Heineman: [00:36:22] Well, we most recently were in Yellowstone a couple times. We love Yellowstone. I've had a connection there since I was a kid.

Juanita Vero: [00:36:28] Okay. The photograph that you've made that's moved you the most recently.

Sara Heineman: [00:36:32] I would have to say this was from a number of years ago, but this was my spirit bear trip in British Columbia.

Juanita Vero: [00:36:38] Oh.

Sara Heineman: [00:36:39] So spirit bear is a it's a bear or a white?

Juanita Vero: [00:36:42] Yeah.

Josh Slotnick: [00:36:43] A white black bear.

Juanita Vero: [00:36:44] You got a photo of a spirit bear.

Sara Heineman: [00:36:46] Two spirit bears. 

Josh Slotnick: [00:36:48] Whoa! How did you do it?

Sara Heineman: [00:36:49] We went on a boat, a sailboat with a tour company, and we went out into a very remote area in British Columbia and were invited by the First Nations to come on on their island. And, um, just got to experience a day with the bears coming down and feeding in the.

Juanita Vero: [00:37:05] So what's the photograph?

Sara Heineman: [00:37:07] Uh, I have many photographs.

Juanita Vero: [00:37:10] Oh, no. Just one. What's the one? The one photo.

Sara Heineman: [00:37:12] I think it was the. It's. She's the National Geographic cover bear. It's great. Grandma. I got to meet her. And so that was. Wow. She's. She was old in 2017, and she was still holding her own, catching fish and eating the heads off, just like all the other bears. And, um, she looked great. So it was incredible. That was a very moving experience.

Juanita Vero: [00:37:35] Oh.

Josh Slotnick: [00:37:35] That's awesome, good for you. Well done and well done to you both on the work you do. And we really, really benefit. Thank you.

Juanita Vero: [00:37:43] Yeah, yeah.

Josh Slotnick: [00:37:43] Thank you.

Jeanna Miller: [00:37:44] Thanks for having us. Yeah.

Josh Slotnick: [00:37:45] Thanks for coming today. Thank you for listening. Thanks for listening to the agenda. If you enjoy these conversations, it would mean a lot if you would rate and review the show on whichever podcast app you use.

Juanita Vero: [00:37:57] And if you know a friend who would like to keep up with what's happening in local government, be sure to recommend this podcast to them.

Dave Strohmaier: [00:38:03] The agenda with the Missoula County Commissioners is made possible with support from Missoula Community Access Television, better known as MCAT, and our staff in Missoula County Communications Division.

Josh Slotnick: [00:38:15] If you have a question or a topic you'd like us to discuss on a future episode, email it to communications@missoulacounty.us.

Juanita Vero: [00:38:22] To find out other ways to stay up to date with what's happening in Missoula County, go to Missoula.

Dave Strohmaier: [00:38:30] Thanks for listening.