22 January 2021 Blog Post: COVID-19 Update in Los Angeles County

22 January 2021 Blog Post: COVID-19 Update in Los Angeles County

Both case rates and mortality rates in Los Angeles County have dropped sharply over the last two weeks (see graphs below).

We saw the highest incident case rate the week ending December 22nd, 2020 (the County reports to the State on Tuesdays, so the “week end” is a Tuesday) at 137.7 new daily cases per 100,000 population. For the week ending this Tuesday, that rate has plummeted to 81.4.

A similar trend is seen in mortality rates (remember: more cases lead to more hospitalizations which lead to more deaths). A maximum mortality rate was seen the week ending January 5th, 2021 (also remember deaths will lag by 2-3 weeks from a case peak) of 1.34 daily deaths per 100,000 population. We now have 0.23 daily deaths per 100,000 population in Los Angeles County.

The magnitude of the drop offs is striking, and hopeful. However, I suspect that there is an element of delayed reporting as well – perhaps from the recent holiday or from the Health Department now being occupied with a vaccine rollout.

Until next week’s numbers, lets keep an eye on the raw values reported today: 81.4 case rate, 0.23 mortality rate for the week ending 1/19/2021. Let’s see if these revise upwards in the weeks ahead.

Also I have additional concerns about the B.1.1.7 variant for both case rates (more infectious/transmissible) and mortality rates (information from the UK today suggest that is may be more lethal as well). More on this tomorrow…

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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21 January 2021 Post: Answering some questions on our website

21 January 2021 Post: Answering some questions on our website

I received the following question on our website (drbretsky.com). I thought it was worth posting.

Question: Will the new Executive Order by Chair of LA County Board of Supervisors Hilda Solis, ordering LA County to make Covid -19 vaccinations available to residents over 65, starting January 21st, speed up vaccines arriving at medical groups, like Dr. Bretsky’s office? I am trying to avoid pharmacies and the Stadiums!

My Answer: The Executive Order widening criteria of who is eligible for vaccination did not come with a request or mandate to increase vaccine supply. So, in essence, it is an empty gesture. At the writing, the County of Los Angeles has unilaterally decided to provide vaccines through 5 sites - each of which at maximum capacity will vaccine 4,000 patients a day. Because the vaccine is a two dose series, it will take the County 2.7 years to vaccinate the 10 million residences of the County. There has been no additional allocation to individual physician's offices (ours has been State and CDC certified since December 17th, 2020) or health systems (can refer to recent statements by Providence and UCLA Health).
Dr. Philip Brestky

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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16 January 2021 Post: COVID Outbreaks Skyrocket at SoCal Supermarkets

16 January 2021 Post: COVID Outbreaks Skyrocket at SoCal Supermarkets

In Los Angeles County, public health department data shows outbreaks at food facilities, like supermarkets are exponentially since November. 

By: Joel Grover and Josh Davis

It is one of the few places many of us still go during the pandemic—the grocery store. 

But beware: the number of COVID-19 outbreaks at Southern California supermarkets continues to skyrocket.  

The NBC4 I-Team has discovered 146 outbreaks last month alone at supermarkets in the the southern part of LA County and in Orange County, according to data obtained from the United Food and Commercial Workers Local 324.

Those numbers include outbreaks at 31 Ralphs stores in the region, 17 Vons, and 16 Albertsons.

In Los Angeles County, public health department data shows outbreaks at food facilities, like supermarkets are up exponentially since early November.

“Every time I go to work, I get scared about the risk,” said Marisela Gonzalez, who works in produce at Albertsons in Tustin and contracted COVID.

Gonzalez says the other five members of her household got infected–including her 29-year old daughter–and she believes she passed the virus to them.

“I thought I was going to lose my daughter, but I couldn’t even go to the hospital with her because I was also sick,” said Gonzalez.

Public health officials say many grocery store workers pick up the virus at work and spread it to their families. 

“These increases (in outbreaks) reflect a pattern of transmission, from work site to home, and back to work site,” said LA County’s director of Public Health, Dr. Barbara Ferrer.

Workers like Marisela Gonzalez believe the grocery chains should resume giving them hazard pay for working in a high-risk environment, like they did last March to June. Chains that own Albertsons and Vons have had double digit increases in profits the first half of the pandemic, according to a report from the non-profit Brookings Institution. 

“We believe that hazard pay should have never stopped.  The hazards are getting worse and worse and yet the hazard pay has stopped,” said Andrea Zinder of UFCW Local 324.

Even with the hazards of working in a crowded supermarket, Marisela Gonzalez returned to work after taking two months off to recover from COVID.

“I have to work.  I have no choice.  I know it’s a big risk, but I have to go back to work.”

The companies that own Albertsons, Vons, and Ralphs all say they’ve invested heavily in safety measures to prevent the spread of COVID-19 at their stores, including frequent disinfecting and monitoring stores to control crowd size and enforce mask requirements.

Full Statement from Albertsons:

Albertsons and Vons are doing everything we can to prioritize the health and safety of our associates, customers, and communities and to ensure our customers have access to the food, medications, and other essential goods they need at this critical time. We are preparing and expanding our trained pharmacy teams to handle the unprecedented demand and administer the vaccine safely and efficiently to the communities we serve as it becomes available. To offer customers education, updates, and convenient scheduling solutions for COVID immunization, Albertsons Cos. launched a new website on each of its banners’ websites featuring FAQs and education on the eligibility criteria.

Throughout this pandemic, the health and safety of everyone who walks through our doors has been our top priority. We comply with local city and county health ordinances including staffing at the front door to monitor occupancy limits and compliance with face coverings as well as clean and sanitize shopping carts.  We require customers across all of our locations to wear face coverings when shopping with us, for their protection and for that of our associates. We appreciate everyone’s diligence, cooperation, and support as we all work together to get through these difficult times as safely as possible.

In addition, our stores have taken many precautions, including:

  • Installing kiosks to conduct health screening and temperature checks to check for COVID symptoms before associates begin their shift.
  • Installing customer line-queuing at checkout.
  • Installing Plexiglas sneeze guards at check stands.
  • Placing social distancing posters and floor markers in the stores.
  • Pausing self-service operations like soup bars, wing bars, and salad bars.
  • Enhancing measures to clean and disinfect all departments, restrooms, and other high touchpoints of the store throughout the day.
  • Making cart wipes and hand sanitizer stations available at key locations within the store for customers’ convenience.
  • Ensuring that store associates can wash their hands at least one time per hour and stay home if they feel sick.
  • Reserving special times for seniors and other vulnerable shoppers who must leave home to obtain their groceries. We ask our non-senior and non-at-risk customers to avoid shopping at these times.

Full Statement from Kroger:

What steps has your company taken to prevent the spread of COVID-19 in supermarkets, to protect workers and customers?

Our most urgent priority throughout this pandemic has been to provide a safe environment for our associates and customers while meeting our societal obligation to provide open stores and access to fresh, affordable food. We would not operate stores that are hazardous to our associates and customers, which is why we’ve invested $1.3 billion to both reward associates and to implement dozens of safety measures. We began implementing these safety measures early in the pandemic and since that time have only strengthened our vigilance and resolve.  Here are just a few of our safety measures:

·         Supplying and requiring our associates to wear protective masks and requiring our customers to wear masks when shopping in our stores. We also provide face shields and gloves upon request.

·         Installed and continuing the use of plexiglass partitions and physical distancing floor decals to promote physical distancing at check lanes and other counters throughout our stores. 

  • Associates are reminded every 30 minutes to wash their hands and to disinfect work stations. In store audio reminders occur for the benefit of our associates and customers reminding them to wear a mask, wash hands and maintain physical distancing.
  •  
  • Continuing to enact our Emergency Leave Guidelines, allowing paid time off for associates diagnosed with COVID-19, placed under mandatory quarantine by their medical provider because of COVID-19 or practicing self-isolation for symptoms verified by an accredited health care professional. All eligible associates will receive their standard pay for up to two weeks (14 days).  
  •  
  • Hiring more than 5,000 new associates from hard hit industries to ensure we can meet public demand for safe shopping practices, like our Pickup service and to ensure proper sanitation in our stores.

·         Offering $15 million through the Helping Hands fund to provide financial assistance to associates who face hardship due to COVID-19. 

·         Providing access to mental health services and other benefits to support associates’ holistic wellbeing during this stressful time. We also offer an associate hotline to ensure benefit questions are answered quickly. 

  • Offering free COVID-19 testing to associates based on symptoms and medical need. 
  •  
  • Continuing to provide comprehensive benefits packages, including world-class healthcare coverage and stable retirement benefits. 
  •  
  • We have received the COVID-19 vaccine at our stores in Los Angeles, Riverside, San Bernardino, Ventura and San Diego Counties and we have begun administering doses to our pharmacy teams and other Phase 1A health care professionals in those counties. Also, through our advocacy efforts, we have been able to get all grocery associates throughout California moved up to Phase 1B of the vaccine distribution, which is expected to commence soon.
  •  
  • The Los Angeles County Public Health list that you have referenced in previous stories currently shows no Ralphs locations under the category of Non-Residential Settings Meeting the Criteria of Three or More Laboratory-confirmed COVID-19 Cases.

Why aren’t there specific monitors (employees or security guards) at entrances to all stores to keep a lower number of customers in the stores at one time, and to ensure customers are wearing masks?

Here’s why you won’t be seeing employees monitor our entrances, but to be clear we are monitoring capacity. Ralphs follows all state, county and city mandates that currently allow 35% capacity in grocery stores. All Ralphs stores are equipped with QueVision, our industry-leading technology system that uses sensors and predictive analytics, helping us to monitor and maintain safe traffic flow in and out of our stores. QueVision uses infrared technology to track the number of customers entering and exiting our doors allowing us to provide a safe, physically distanced shopping experience. When the technology tells our store leader that we are nearing our capacity limit, we will place an associate at the doors to monitor traffic until the rush subsides. Each store leader carries a device that lets them know what the current capacity is and alerts them if capacity limits are being approached.

Why isn’t the company currently paying some kind of hourly bonus (hazard pay/hero pay) to supermarket workers, despite your company making record profits in 2020? Does your company have any plans to bring back that extra hourly pay or some form of hazard pay bonus?

As mentioned earlier, we have invested more than $1.3 billion since March to reward our associates and safeguard associates and customers. These investments include associate bonuses, wage premiums, store credits and fuel points, paid leave, testing, personal protective equipment and contributions to the company’s Helping Hands fund. In addition to COVID-19-related appreciation and safety measures, we continue investing in permanent wage increases for our frontline associates. Over the period of 2018 to 2020, we will have invested an incremental $800 million in associate wage increases across our family of companies. Did you know that the average compensation rate at Los Angeles County Ralphs locations is nearly $26 per hour with benefits like health care and retirement benefits factored in? Again, we would not operate stores that are hazardous to our associates and customers, which is why Ralphs has already made such a large investment in our associates and our communities in 2020, including donations to hunger relief organizations exceeding $6 million dollars plus donating another 6 million meals to local food banks that will assist the many thousands of Southern Californians that are currently experiencing job-loss, homelessness and hunger from the pandemic. Additionally, we just assisted NBC4’s Help 4 the Hungry campaign that raised more than half a million dollars for local food banks.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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14 January 2021 Blog Post: On Vaccine Distribution

14 January 2021: On Vaccine Distribution

So today I have had a lot of questions about vaccine distribution as well as excited calls from patients who have been able to make appointments at Ralphs. This came as a surprise to me as Los Angeles County has not yet moved into a phase where those over 65 years of age are even eligible to receive vaccine – the Health Department is still working to vaccine healthcare workers and expects that this process will take until “the beginning of February” to complete.

Link

Here is my general advice in a nutshell on the COVID-19 vaccine, appointments and the roll-out in Los Angeles County:

  • 1. Remember that the COVID-19 vaccine is a series of two shots. Whatever scheduling and logistical gymnastics that you performed to get the first shot will need to be repeated in 21 (Pfizer) or 28 (Moderna) days.
  • 2. Remember that pharmacies and grocery stores vaccinate people by convenience when they are there to pick up medications or when they are shopping. Vaccination is not their primary expertise. They will need to simultaneously manage all their usual pharmacy and grocery store tasks and take on a mass vaccination campaign with not just one but two shots. They have no track record of doing this which is not to say that they are not capable, but just that they have no experience.
  • 3. If you have had severe allergic reactions to previous vaccines, Penicillin or environmental triggers (bee stings) or if you carry an EpiPen – be aware that if you have a vaccination in a pharmacy or a grocery store, the medical professional attending to you may have no experience in managing severe allergic reactions or anaphylaxis. Again, not to say that they will not be capable, but just that this is not their expertise.
  • 4. If you have scheduled Shot #1, there must be some mechanism by which you can schedule Shot #2. The second vaccine dose must be administered within a fairly tight window of about 4 days on either side of when due. If this is lacking, think about some contingency plan. Our office, for instance, should it receive vaccine would certainly prioritize somebody who had one shot and cannot get a second. All vaccines administered are reported to a statewide registry so there is no reason why you would have to get the two shots at the same location (although this would be preferable).
  • 5. Health care professionals who have received their vaccines from Los Angeles County vaccination sites have, without exception, reported professional staff, punctual appointments and an ease in scheduling their second vaccination.
  • 6. While I am sympathetic to those who are looking to rush out of this inexorable period of confinement – particular those 65+ who are at highest risk – there may be some benefit in waiting to see how the process unfolds. I have used the analogy of buying a car in the first model year insofar as it may be useful to let some of the kinks in the system work themselves out.
  • 7. Be aware that long lines and lack of physical distancing at a vaccination site could expose you to the virus. If you see or experience this, it may be reasonable to wait rather than risking exposure.

I am sure there are other concerns and tips that I am missing so please feel to add comments or ask questions in the comments below. I am hopeful that we can pull off this unprecedented mass vaccination effort. I am, on the other hand, acutely aware that the CDC, State Health Department and County Health Department have stumbled badly at nearly every critical juncture in this pandemic – from testing, to masking, to contact tracing, to premature lifting of shelter-in-place and now to way too slow vaccination distribution. As every financial commercial says “past performance is not indicative of future results” – but suffice it to say I have accumulated more than enough pessimism over the past 10 months to be skeptical.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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11 January 2021 Blog Post: Current COVID-19 Outlook in Los Angeles

11 January 2021: Current COVID-19 Outlook in Los Angeles

You may have already heard the news that Los Angeles will transition the Dodger Stadium testing supersite into “a mass vaccination center” by week’s end. This move is occurring as the COVID-19 vaccine rollout has failed by all measures.

Although an attractive option to transform a testing center into a vaccine center, this move is misguided and is emblematic of a panicked decision made by an overloaded Public Health Department.  In doing so, Los Angeles is hoping to shift resources from one priority to the next.

The problem is, however, that Los Angeles has missed the point that there are now two concurrent and equality pressing priorities which need to be addressed simultaneously.  This is illustrated by the fact that we are now back near the highest case rates ever (Figure 1) at 130.5 new daily cases per 100,000 population (previous high:  135.9). 

Testing rates are down 30% from their 12/22/2020 peak (Figure 2) and removing the largest coronavirus testing site in the nation will only serve as a further bottleneck.

I agree that testing sites are a natural venue for vaccination – but these efforts need to be concurrent, not mutually exclusive.  Dodger Stadium has multiple entrances and is perfect to run two efforts. But the problem?  Too few resources.

I agree that testing sites are a natural venue for vaccination – but these efforts need to be concurrent, not mutually exclusive.  Dodger Stadium has multiple entrances and is perfect to run two efforts. But the problem?  Too few resources.

For some reason, Los Angeles and the Health Department have insisted upon taking over the entire community vaccination effort themselves. There is no reasonable historical expectation that they should be able to manage this effort. Health Departments only provide 1% of the annual influenza vaccinations so to task them to suddenly provide vaccines to all except those on staff at hospitals is far outside of their scope of expertise or capability.

But at the end of the day, the fact that Los Angeles cannot get out of its own way on this issue is costing lives.  The most recent mortality rate is now 1.34 daily deaths per 100,000 population which is the highest it has been since the start of the pandemic.  This rate has increased every single week since 11/10/2020.

At this point we need the County, the City and the Public Health Department to do everything well.  Sacrificing testing for vaccination is the epidemiologic equivalent of robbing Peter to pay Paul. If they cannot manage it themselves, then they need to ask for help.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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9 January 2021 Post: Bullet points from my TV interview with Spectrum News 1 SoCal yesterday

9 January 2021 Post: Bullet points from my TV interview with Spectrum News 1 SoCal yesterday

1. Rapid antigen testing can and should be widely deployed in healthcare offices.

2. Vaccine roll out has been, bottom line, way too slow.

3. If we cannot rapidly and effectively vaccinate healthcare workers at their workplace, how do we expect to be able to vaccinate the general public?

4. Primary care offices (which include Internal Medicine, Family Medicine, Pediatrics, and OB/GYN) need to be included in the vaccine distribution process if we are to be successful in any mass vaccination campaign.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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7 January 2021 Blog Post: On Vaccine “Rollout”

7 January 2021 Blog Post: On Vaccine “Rollout”

The failures of the United States public health system to respond to COVID-19 are multiple and well documented. From the CDC botching tests in March, to irregular messaging regarding masks, poorly timed shelter-in-place orders and now the bottlenecks in vaccine rollout the country has misstepped at every conceivable juncture. Now we are at our most critical and, perhaps, most tragic juncture because we have not one but two effective options to stop the pandemic – Pfizer/BioNTech (95% effective at 28 days) and Moderna (94.1% effective). Pfizer obtained FDA clearance on December 11th, Moderna on December 18th.  This Friday, January 8th will be day 28 from the Pfizer approval – deaths that occur after this date can and should be considered to be entirely preventable.

Now I’m not naive enough to believe that the United States could roll out 660 million doses and vaccine the entire population between December 11th 2020 and January 8th 2021. On the other hand, the current data on vaccination rollout nationally (link: https://covid.cdc.gov/covid-data-tracker/#vaccinations) points to our failure (again):

-17 million doses distributed with 4.8 million individuals receiving their first dose (28% effective vaccination rate)

-3.2 million doses distributed to long term care facilities with 429,000 individuals receiving their first dose (13% effective vaccination rate)

California is underperforming the national average – with over 2 million doses received, only 456,980 have received their first dose (22.4%). California is also the current national epicenter of the COVID-19 epidemic (link: https://covid.cdc.gov/covid-data-tracker/#county-view) with Los Angeles, San Bernardino, Orange and Riverside Counties having the highest infection rates in the country.

At a certain point, we move from run of the mill failure to abject failure – and Los Angeles County is now the standard bearer of worst in class response to the pandemic. With cure in hand, the County is now botching rollout, hoarding vaccines and causing tragic and unnecessary morbidity and mortality.  The linked Los Angeles Times article (link: https://covid.cdc.gov/covid-data-tracker/#county-view) draws you in with the flashy headline that non-prioritized individuals have been able to obtain vaccines. But that’s not the most appalling fact in the article, this is:

“Crowds of desperate people seeking early access to the vaccine led to longer lines and headaches for workers at four sites run by the city of Los Angeles set up to provide doses exclusively for healthcare employees.”

Desperate people in a County of 10 million people, a City of 4 million and the public health response?  Four vaccination sites.

My personal experience and attempts to secure vaccines for our clinic has been equally frustrating, maddening and outrageous. We applied and were certified to be a community site for vaccine delivery by the State of California on December 17th – receiving the following chipper response:

“Congrats on being COVIDReadi! With your help and the help of the California healthcare provider team, entire communities will be COVID Ready quicker and more effectively than any vaccination effort in our history.”

When I received no further follow-up from the State I began to ask when I might expect vaccines to be delivered (a not unreasonable request). The State Health Department responded that I needed to ask my local Health Department. Our local Health Department responded that I needed to ask the CDC.  The CDC responded that I needed to speak with somebody at the state-level.

Around and around we go. So how did this get so messed up? The answer probably won’t be surprising, but the fundamental stumbling block is at the top with the CDC.  And here is the root cause -from their vaccination “playbook” drafted in October 2020 (link: https://www.cdc.gov/vaccines/imz-managers/downloads/COVID-19-Vaccination-Program-Interim_Playbook.pdf)

On Page 17 of the playbook, the CDC notes that “To improve vaccination among critical population groups, jurisdictions must ensure these groups have access to vaccination services.” To do so, they suggest that “programs should establish points of contact (POCs) for each organization, employer, or community (as appropriate) within the critical population groups.”  Here is their list of suggested points of contact:

  • Community health centers 
  • Federally Qualified Health Centers
  • Rural Health Centers 
  • Critical access hospitals
  • Pharmacies 
  • Organizations and businesses that employ critical workforce 
  • First responder organizations 
  • Tribal health or community centers 
  • Non-traditional providers (e.g., community health workers, doulas, promotoras) and locations (e.g., dialysis centers, community centers) serving people at higher risk for severe illness 
  • Other locations or facilities for shared or congregate housing serving people at higher risk for COVID-19 illness (e.g., homeless shelters, group housing, correctional facilities, senior living facilities) 
  • Locations where people 65 years of age and older gather (e.g., senior centers, food pantries) 
  • Religious groups and other community groups 
  • In-home care organizations 
  • Schools and institutions of higher learning

Notice anything missing? I do – doctor’s offices. Why is this such an oversight? Well the reason can be found in the CDC’s own data on flu shots. Here are the breakdown of locations of where adults receive their flu shot (most recent data are from 2018 as for location is only collected every three years – link:  https://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2018.htm)

  1. Doctor’s office (34.3%)
  2. Pharmacy/Store (32.2%)
  3. Workplace (14.9%)
  4. Clinic or health center (7.9%)
  5. Emergency Department (5.4%)
  6. Other place (1.9%)
  7. School or college (1.4%)
  8. Health Department (1.0%)
  9. Senior or community center (0.3%)

Doctor’s offices are the largest provider of flu vaccine for adults – that number skyrockets to 67.7% of children. Typically Health Departments which are now charged with the ENTIRE burden of vaccine distribution only supply 1% of flu vaccines.  1%! Yet the CDC completely overlooked doctor’s offices – this in the face of other potential sites being overburdened (Emergency Department and Health Department) or non-viable (workplace, as many are closed due to safer-at-home restriction). Further, the percentage of flu vaccinations performed at a pharmacy is largely a function of convenience – i.e. people are already there picking up prescriptions or shopping so they get their flu shots at the same time. But, again, with the population being asked to limit movement, there are far fewer of those vaccination opportunities. Add into this calculus that the COVID-19 vaccines are a series of 2 shots – so any inefficiencies in the system will be multiplied by a factor of 2. Standing in a long line for hours? You’ll do it twice. Traveled a long distance to get a shot? You’ll do it twice. Any inconvenience reduces the likelihood of individuals completing the vaccine series – leading to no protection or partial protection thus creating an environment where viral mutations can thrive.

In the final analysis, the effectiveness of any vaccine distribution effort can be easily measured as a function of doses delivered by doses available. At this writing – nationally, 28% of available vaccination doses have been administered and in California that percentage drops to 22%.

We can – and must – do better.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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