Against the backdrop of waning public demand for covid-19 vaccinations in the state, a new problem is emerging: Some Arkansans are not showing up for the second dose of their shots.
While there is a single-dose vaccine made by Johnson & Johnson, the other two vaccines -- Moderna's and Pfizer-BioNTech's -- require a second dose about three weeks after the initial shot to achieve maximum immunity from the coronavirus.
Public health officials say in recent weeks they have noticed a worrying trend of people not showing up for their second dose. The state tracks covid-19 immunizations via a centralized system where health care providers report on the vaccinations they have given each week.
This is concerning, they say, because while some protection against the coronavirus is offered by one dose, full immunity is not achieved until at least two weeks after the second dose, leaving those with only one shot still susceptible to catching potentially severe cases of the virus and spreading it to others.
"About 12 or 13%" of people who have gotten either a Moderna or Pfizer vaccine have not returned for their second shot, said Dr. Jennifer Dillaha, state epidemiologist.
As of Sunday morning, more than 358,000 people had been partly immunized in the state, according to data from the Arkansas Department of Health. Twelve percent of that figure would mean about 43,000 people have not gotten second doses.
"I am moderately concerned to very concerned, because it is very important for people to gain as much immunity as they can against the virus that causes covid-19," Dillaha said. "We should not miss the opportunity for that."
Dillaha said ideally patients should receive a second dose within a 42-day window, but can still get the second dose beyond that time frame without having to start the series over.
She said people cannot substitute the single-dose J&J vaccine for the two-dose regimen of the others.
"Unfortunately, I think people underestimate what the virus that causes covid-19 can do to you; even people with mild disease can have long-term problems related to the covid-19 illness," she said. "It would just be a tragedy for someone to experience that when it could have been prevented by getting the second [dose]."
There are myriad reasons why people are not showing up for second appointments.
Pharmacists and other health care providers say sometimes people forget, have a scheduling conflict, believe that one dose is enough protection or are afraid of side effects from a second dose.
"The challenge is trying to sort through what their reasoning is," said Dr. Robert Hopkins, a professor of internal medicine and pediatrics at the University of Arkansas for Medical Sciences.
"Have they scheduled appointments at different places? Did someone have bad side effects with the first dose? Are they reading something from another source that says you don't have to get another dose?" Hopkins said. "It is a serious concern. I don't think it is a catastrophe at this point, but I do think it is a serious concern."
The state Health Department did not have a breakdown providing insight as to whether there are any trends among those who are not returning.
"It would be interesting to know, are the people who are not getting their second dose going to mass-vaccination events? Are they patients of color or patients with English as a second language? Are they white?" said John Vinson, head of the Arkansas Pharmacists Association, a professional group that coordinates vaccine distribution.
"There could be differences depending on who it is and where they got their first dose," Vinson said.
Lelan Stice, a pharmacist and owner of Doctor's Orders Pharmacy, which has locations in Pine Bluff, White Hall and Star City, said there have been issues of no-shows for second shots at mass-vaccination clinics.
Stice assisted with a clinic earlier this year in West Memphis. He said about 900 people showed up for the first shot but only 700 returned for the booster several weeks later.
For the small, independent pharmacies that often assist with mass clinics, there is not necessarily enough manpower available for them to keep track of patients and remind them to come for second appointments.
Many times they operate on faith that people will return, but know they must have contingency plans so unused doses do not go to waste, Stice said.
"It makes it a little more difficult to plan," Stice said. "It is very hard for us to track. We could look for it in our billing information, but it takes us a couple of weeks after we have administered the shots before we can get through all of the billing."
About 5% of patients scheduled to return for second-dose clinics are no-shows at Freiderica Pharmacy & Compounding in Little Rock, said Lyn Fruchey, pharmacist and owner of the business.
That number would be greater if the pharmacy did not call people who do not show up and reschedule them for another day, Fruchey said.
Many people forget or have a scheduling conflict, the pharmacist said.
"If we were not calling them and trying to get them in or rescheduling them based on things coming up in their lives, we would probably be closer to 10% who don't get their second dose," Fruchey said. "If we have a clinic for 150 second doses, we might have 15 who don't end up getting their second dose on the day we scheduled them for."
"There is a need for a concentrated effort to help get people motivated," Fruchey said. "If we just fiddle around with this and end up with about 30 percent [of the population in Arkansas] immunized, there's the likelihood we might get an additional surge coming through."
"We have to figure out a way to be able to reach those people," he said.
Dillaha, the state epidemiologist, said the Health Department is "taking steps" to plan an outreach program for people who have not gotten a second dose. That could include mailing flyers to remind people of appointments or text messages.
"We are planning to have some type of follow-up," Dillaha said. "I don't know how it will look."
Dillaha said that even before covid-19, public health officials have struggled with fully immunizing people with other vaccines that require more than one shot.
"There are few vaccines that are only a single dose," she said. "We are used to expecting that not everyone will get their second dose on time, and working with people to understand the importance as well as to remind them and to remove barriers to them getting that second shot."