SEATTLE – Before the pandemic, the Exhibition Hall at the Seattle Center was the site of fashion shows, high-society galas and book fairs; the Pacific Northwest Ballet practices a floor above and performs mere yards away.

Since March 2020, the hall has been one of the largest emergency homeless shelters of its kind in the region, with 130 cots spaced 6 feet apart, covering the 34,000-square-foot floor. And on April 2, it became a vaccination clinic after 130 shots of the Johnson & Johnson vaccine arrived there for one of the state’s newly eligible – and most challenging – priority groups.

A little after 11 a.m. that day, a loudspeaker crackled from the 20-foot ceiling.

“Good morning everyone,” said Sam McKnight, shelter program manager for the Downtown Emergency Services Center, the nonprofit running the shelter. “Again, I hope you’re all getting vaccinated.”

By noon, they’d only had 35 takers, according to Alix Van Hollebeke, the nonprofit’s nursing director.

“It’s a sleepy clinic today,” Van Hollebeke said. She was already planning to take unused doses out to street encampments.

Still, by the end of the day, less than half the doses had been used.

This month, Seattle–area shelters are embarking on a daunting task: vaccinating more than 10,000 people without stable dwellings, the most of any metro area in America except Los Angeles and New York.

Officials expect that vaccination effort to take much longer than reaching the general population. Over the next however-long-it-takes, medical teams and public health staff plan to visit 669 sites in King County – shelters, transitional and permanent housing for formerly homeless people, hotels, tent cities and tiny house villages hosted at churches or on city land, and 85 unsanctioned encampments all over the city.

They’ve overcome obstacles to get here – one being quietly persuading the state to move up the timeline for homeless people’s eligibility so they could start at the beginning of April. But the biggest obstacle is ahead: persuading a population with unusually high vaccine hesitance.

This is not going to be like the early vaccine blitzes at long-term care facilities where the virus claimed many victims. If staff want to achieve herd immunity in the homeless population, they’re likely going to have to keep coming back.

Last week, 157 vaccines went into arms at the biggest Downtown Emergency Service Center shelters – Exhibition Hall, the Navigation Center and the Red Lion hotel in Renton – but there are 400 people living in those three spaces, meaning the acceptance rate is just under 40%. Some people were out of the shelter during the clinic, at work, on the streets, or at a doctors’ appointment. Many just refused.

More clinics at more shelters are planned for the coming weeks, and service-center staff plan to go back to the already-visited shelters “at some point,” a spokesperson said.

David Spisak, 61, got the vaccine April 2, but said his shelter-mates are concerned about the fast-tracked approval of the Johnson & Johnson vaccine – and many of them are mentally ill, with schizophrenia or paranoia, making them potentially susceptible to misinformation about its safety.

“They repeat things they hear, like a parrot’s script,” Spisak said.

About half of people living in shelter in Seattle are resistant or unsure if they want to take the vaccine, according to researchers at the University of Washington’s Seattle Flu Study. Preliminary numbers from surveys of 880 Seattle shelter residents in the past few months show 32% would not get a COVID-19 vaccine and 19% were undecided – and that’s among people who volunteered for the study, who are probably more trusting than the average, said Dr. Helen Chu, a lead researcher for the study.

That’s higher hesitancy than polling shows among the general population, of which only 13% would definitely not get the vaccine, 7% wouldn’t get it unless required and 17% would wait and see, according to a Kaiser Family Foundation poll released in March.

But it’s not so much mental illness driving hesitancy, Chu said, as lower education levels and socio-economic status that tend to correlate with a distrust of institutional medicine. People who grew up poor, and people of color – people who haven’t historically had access to the same education and health care as better-off white people – are more likely to end up homeless. Many have also been treated poorly by medical institutions.

“I think the larger amount of people who are not going to get it just are people who have suspicion of science, of the institution, of medical providers and medical care,” Chu said.

Omar Mustafa, 29, was one of those skeptical shelter residents at Exhibition Hall last week. He believes the coronavirus is real and wears a mask around his grandparents, but if anything, he’s too scared of the disease to get a vaccine. He, like many, believes that the vaccine contains the virus that causes COVID-19, even though the Johnson & Johnson vaccine actually uses a disabled adenovirus, which isn’t related to the coronavirus.

“This virus has been killing us off and you want me to put this in my body?” Mustafa said.

This skepticism compounds logistical hurdles, creating a unique and particular challenge for Public Health – Seattle & King County. The closest comparison to a mass vaccination campaign for people living homeless is a successful hepatitis A vaccination campaign that started in October 2017 and had administered about 5,800 doses as of March 2021. In its busiest month 557 people were vaccinated, but most months averaged less than 150. The county will have to administer many more a lot faster to get homeless people to a safe place any time soon.

If shelter operators can’t manage to get vaccination rates to the 70% or 80% needed to essentially stop the spread of the virus, the specter of future deaths is very real.

Dr. Stephen Hwang, a shelter doctor and researcher at the University of Toronto who has studied respiratory disease spread in homeless shelters, said shelters there may be experiencing a similar rate of uptake – roughly 40%, from what he’s seen himself and heard anecdotally.

Shelters will need to offer vaccines to their populations, Hwang said, and keep returning. Otherwise, shelters could foster COVID-19 outbreaks seasonally and more variants could develop.

“We’re early in the vaccination campaign,” Hwang said. “There’s still hope that people will change their minds as they see the vast majority of people get vaccinated and the beneficial effects it has on people’s lives. I think it’s too early to say that someone who says ‘no’ today will say ‘no’ for the next year.”

Nurses, outreach and shelter workers have a few assets on their side: Many have spent years building relationships with street and shelter dwellers through programs like the hepatitis A vaccination campaign, and while homeless people might not trust pharmaceutical companies, they sometimes learn to trust the people tasked with helping.

Days before the April 2 clinic, public health employees hosted a question-and-answer session at Exhibition Hall to allay fears. Places like this, where turnover is much higher than in hotels or spaces where people have private rooms, are tougher because staff don’t always have long relationships with clients.

“Fear drives a lot of people’s behavior, I think,” said Jesse Klein, 35, another Exhibition Hall shelter resident who agreed to get the vaccine on April 2. He said the fact that the vaccine was one shot persuaded him to get it: A two-dose vaccine would have been too complicated for him and a lot of people who might not know where they will sleep the next night.