WASHINGTON — Now that President Joe Biden has met his goal to have all adults eligible for the coronavirus vaccine, health officials around the country are hitting what appears to be a soft ceiling: More than half the nation’s adults have received at least one dose, but it is going to take hard work — and some creative changes in strategy — to convince the rest.

State health officials, business leaders, policymakers and politicians are struggling to figure out how to tailor their messages, and their tactics, to persuade not only the vaccine hesitant but also the indifferent. Officials in many states are looking past mass vaccination sites and toward having patients get vaccinated by their own doctors, where people are most at ease — a shift that will require the Biden administration to ship vaccine in much smaller quantities.

White House and state health officials are calling this next phase of the vaccination campaign “the ground game,” and are likening it to a get-out-the-vote effort. The work will be labor intensive — much of it may fall on private employers — but the risk is clear: If it takes too long to reach “herd immunity,” the point at which the spread of the virus slows, worrisome new variants could emerge that evade the vaccine.

“If you think of this as a war,” said Michael Carney, senior vice president for emerging issues at the U.S. Chamber of Commerce Foundation, “we’re about to enter the hand-to-hand combat phase of the war.”

On Wednesday, Biden urged all employers in the United States to offer full pay to their workers for time off to be inoculated and to recover from any aftereffects. He also announced a paid leave tax credit to offset the cost for companies with fewer than 500 employees, and appealed to the unvaccinated to get their shots.

“If we let up now and stop being vigilant,” he warned, “this virus will erase the progress we have already achieved.”


The president’s plea came as he marked “an incredible achievement by the nation” — 200 million shots in the arms of the American people, a target he said the nation would hit on Wednesday, with a week to go before his 100th day in office. By Thursday, Biden said, more than 80% of Americans older than 65 will have had their shots.

But the distribution is uneven: While New Hampshire has given at least one shot to 59% of its citizens (that figure includes children, most of whom are not yet eligible), Mississippi and Alabama are languishing at 30%.

The laggards are trying to adjust. In Louisiana, where 40% of the adult population has had one shot even though all adults have been eligible since March, officials are delivering doses to commercial fishermen near the docks and running pop-up clinics at a Buddhist temple, homeless shelters and truck stops. Civic groups are conducting door-to-door visits, akin to a get-out-the-vote effort, in neighborhoods with low vaccination rates.

In Alabama, Dr. Scott Harris, the state health officer, is trying to reach rural white residents, who are mistrustful of politicians and the news media. Harris is asking doctors to record cellphone videos, with a plea: “Please email them to your patients, saying, ‘This is why I think you ought to take the vaccine.’”

Some companies are contemplating their own vaccine clinics and educating their workers about the benefits of protecting themselves against a virus that has killed more than 568,000 people in the U.S. Others are talking about giving their workers incentives, like cash gift cards — a notion Biden raised in his remarks at the White House on Wednesday.

Shirley Bloomfield, CEO of NTCA — The Rural Broadband Association, which represents small, rural telecommunications companies, has been working with the White House on pushing her members to get the vaccine.


“One of my CEOs is paying everyone $100 to get the vaccine,” she said. “I think we all have to be a little more creative because we’re seeing that saturation point.”

Vaccine mandates could be an option, just as many employers led campaigns to ban indoor smoking. The Equal Employment Opportunity Commission has told employers that they can require vaccination to protect public health.

But with Republicans arguing that mandates amount to an intrusion on personal liberty, the White House is steering clear of the discussion, saying the decision to require vaccination or proof of it will be left to individual employers. And with the economy gearing up, managers are reluctant to demand inoculation, fearing too many employees would seek work elsewhere.

“Employers feel that COVID has caused such stress on their people, they are reticent to put on any more pressure,” said Kathryn Wylde, president of the Partnership for New York City, the city’s leading business organization.

White House officials say they take it as a good sign that more than 51% of U.S. adults have turned out for a first dose — an indication that “there are tens of millions of people who are still eager to get vaccinated,” said Dr. Bechara Choucair, the White House vaccinations coordinator. But he is aware that Americans will soon no longer be fighting for vaccine slots, and supply will exceed demand.

In some parts of the country, that point may be here. In Mississippi, which opened vaccinations to all adults a month ago, 21% of the population is fully inoculated. In Alabama, the figure is just 19%. In Georgia, home of the Centers for Disease Control and Prevention, just 20% of the population is fully vaccinated.


“There are states where they feel they have hit the wall,” said Michael Fraser, executive director of the Association of State and Territorial Health Officials. “The folks that wanted it have found it. The folks that don’t want it are not bothering to find it.”

The fear is that even as some regions like New England race toward broad immunity, others will harbor coronavirus infections that could transform into more dangerous and more contagious variants, which could break through existing vaccinations.

While estimates of what it takes to reach herd immunity vary, most experts put the figure at 70% to 90% of the population. That figure includes children, who are not yet eligible to be vaccinated. And judging by the vaccination rates so far, herd immunity will be difficult to reach, particularly in the South.

Last week, Choucair said, the CDC began working with states to identify primary care doctors in neighborhoods with a high “social vulnerability index” to get them vaccines.

“It’s really going to be all about the ground game,” Choucair said. “It’s going to be about planning at the local level. It’s going to be about microplans. It’s going to be about county by county, ZIP code by ZIP code, census tract by census tract to make sure what are the strategies that work.”

Polls show that vaccine hesitancy is on the decline, as more people see their friends and relatives get vaccinated without incident. John Bridgeland, a founder and CEO of the COVID Collaborative, a bipartisan group of political and scientific leaders working on vaccine education, said the challenge was not being dogmatic in a public awareness campaign, but treating every person’s concern as unique and valid.


“People have very legitimate concerns,” Bridgeland said, “and they need good answers from trusted people.”

Complicating such reassurances is rising concern about vaccine safety after the government’s decision to “pause” the single-dose Johnson & Johnson vaccine while regulators investigate reports of rare blood clots among six female recipients.

A CDC advisory panel is expected to meet Friday to determine whether to place restrictions on use of the vaccine, which public health officials had expected to use in hard-to-reach communities, like homeless shelters.

In the meantime, Fraser said his organization was exploring ways to move away from mass vaccination clinics, which assume “everybody in the population is really chomping at the bit to get vaccinated,” toward “more retail public health,” in which state and local health departments and providers reach out directly to the unvaccinated.

In some states, there have been surprises. In Alabama, Harris said, officials prepared extensively to address vaccine hesitancy among African Americans and put “a lot of time into trying to build local relationships with trusted voices” — an effort that he said paid off. But officials did not anticipate such strong resistance from rural white residents.

The state has done polling to figure out how to persuade that group, and learned that the best way to reach those residents would be through their own doctors. Yet having individual doctors administer the vaccine poses a logistical challenge for pharmaceutical companies and the Biden administration, which ships doses to states in large quantities.


One vaccine maker, Pfizer-BioNTech, ships 1,170 doses in a single pallet; the other, Moderna, ships packets of 10 vials containing 100 doses. State health officials are working with the Biden administration to receive smaller shipments, and are hoping for single-dose, pre-filled syringes, which some experts say might not be possible because of supply chain constraints.

“We need to get smaller volume of the vaccine so that you’re not opening a vial and then having to throw it away after giving three or four doses,” Dr. Jose Romero, the Arkansas health secretary and chairperson of the CDC advisory panel on vaccines, said Wednesday. “Either that or the federal government is going to have to accept the fact that we are going to be having a lot of wastage to get this done.”

In New York, Gov. Andrew Cuomo said Wednesday that as of Friday, people 60 and older could get vaccinated at 16 state-run mass vaccination sites without an appointment.

Private employers may be the next pressure point. The private sector is eager to jump in and help educate employees — and even administer vaccines. But even with broad public awareness campaigns, television commercials, and incentives like cash payments and personal time off, Bloomfield, of the rural broadband association, said vaccination rates among staffs at her member companies were topping out at about 50% to 60%.

On top of that, Bloomfield said her members reported to her that as many as 15% of people in small towns were not showing up for their second shot. She attributed some of that to social media posts about side effects. “That doesn’t help us,” she said.