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February 18, 2021

Taking Vaccine to Where the Virus Is—Equity and Effectiveness in Coronavirus Vaccinations

Author Affiliations
  • 1Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 2Department of Medicine, University of California, San Francisco
  • 3School of Public Health, University of California, Berkeley
JAMA Health Forum. 2021;2(2):e210213. doi:10.1001/jamahealthforum.2021.0213

The urgency to accelerate vaccinations in the face of the recent coronavirus disease 2019 (COVID-19) pandemic surge and the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants has led many to adopt a simplified age-based prioritization strategy for COVID-19 vaccine allocation. The rationale for this approach is that implementation will be simpler and overall deaths will be fewer, though proponents often acknowledge that equity may take a back seat because of the overriding need for efficiency. This article outlines an approach to achieve equity, efficiency, and ultimately effectiveness in the COVID-19 vaccination campaign.

Black, Latino, Indigenous, and Pacific Islander populations and low-income communities generally have borne the brunt of the COVID-19 pandemic. There are several social and structural reasons for this disproportionate burden. Many individuals from these communities perform essential in-person work (often without adequate protection for workers or enforcement of workplace health orders), live in crowded housing (exacerbated in areas with existing housing affordability crises) and in poverty, and have limited access to and trust in a daunting and fragmented health care system.

Without an explicit focus on equity in a vaccination strategy, these COVID-19 disparities will certainly widen both because the same structural barriers will limit accessibility to vaccines among those aged 65 years or older and because these populations are overrepresented among the deaths in those younger aged than 65 years. Moreover, strategies that ignore equity risk undermining the effectiveness of vaccination as a tool to control the pandemic, potentially increasing hospitalizations and deaths in addition to widening disparities.

One pathway for achieving an equity focus is incorporating place-based vaccine prioritization into the overall strategy of mobilizing communities and distributing vaccines in areas within a city or county that have been disproportionately affected by SARS-CoV-2 infections, hospitalizations, and deaths.

Because of historical and contemporary redlining and other structural inequalities in housing and services, place often captures the social vulnerability at the heart of COVID-19 risk. Transmission of SARS-CoV-2 infection is clearly patterned by place, as evidenced by the ubiquitous maps showing unequal distribution of COVID-19 cases and deaths within cities and counties. Place also offers built-in efficiencies for community mobilization, education, and distribution, which already has been observed for community-based testing. A place-based approach can be implemented efficiently according to the principles below.

Focus on Zip Codes With the Greatest Numbers of COVID-19 Cases, Hospitalizations, and Deaths per Capita Within a Region

Many excellent measures of neighborhood social vulnerability exist that aggregate at the Census tract level and are linked to COVID-19 outcomes. But the truth is that the pandemic itself has been its own stress test, revealing the neighborhood social vulnerabilities that exist within cities and counties. The best and most relevant measure of these vulnerabilities is simply the effect of the pandemic itself in the places with higher COVID-19 case counts, hospitalizations, and deaths within a given region.

Census tracts may better capture the heterogeneity that exists in smaller geographic areas; however, for ease of implementation, vaccination strategies according to zip codes may achieve the same overall purpose. Zip codes are understood by the public, are easy for health care systems and pharmacies to implement, and are compatible with mobile and pop-up distribution strategies.

Vaccinate the Entire Community in Hard-Hit Zip Codes

As vaccine supply improves, lowering age requirements should allow for more intensive vaccine distribution in hard-hit areas. Imagine that a 75-year-old grandmother could receive her vaccine with her 40-year-old caregiver at a neighborhood community site or that a restaurant line cook taking time off of work for his vaccine could protect himself and his family with a single visit.

Existing access barriers for many in hard-hit communities are further compounded by the need to communicate and implement a complex tiering system. Liberalizing these tiers in the neighborhoods of interest will enhance the efficiency of community and clinical vaccination sites.

Vaccinating all eligible individuals in areas with high viral transmission has the potential to actively reduce important chains of transmission often associated with younger adults. Disrupting transmission reduces the downstream sequelae of hospitalizations and deaths, thus improving the overall effectiveness of vaccination campaigns. Importantly, although older adults are overrepresented in the deaths from COVID-19, the majority of COVID-19 hospitalizations nationally are among those younger than 65 years. Preventing COVID-19 hospitalizations, particularly in the often underresourced health care facilities that serve hard-hit neighborhoods, should be a goal of an effective vaccination strategy.

Partner With Civic and Community Leaders in Affected Zip Codes to Increase Acceptance

Current vaccination numbers already show evidence that compared with White populations, Black and Latino populations have lower rates of vaccinations, stemming from barriers to effective access as well as from vaccine hesitancy. However, vaccine hesitancy can be overcome, and trusted messengers of vaccine information are critical to achieving high vaccination rates.

Although for some individuals, these trusted messengers will be national figures of prominence, for many others the trusted messengers will be local community leaders and organizers or neighbors who have been vaccinated and can speak to their reasons and address specific local concerns. A well-implemented place-based approach tapping into community power and mobilization can be instrumental in addressing vaccine hesitancy by amplifying the voices and actions of local leaders to directly address the needs and concerns of their neighbors.

Equity is important in the vaccination rollout first and foremost because of the disproportionate burden of illness and death borne by low-income communities and communities of color. However, equity will also drive the effectiveness of vaccine campaigns, focusing efforts to maximize uptake of vaccinations and reductions in transmission, hospitalizations, and deaths. To turn the tide on the COVID-19 pandemic, it is necessary to follow the virus—and use vaccines to shut the virus down where it is causing the most harm. That means taking vaccination campaigns to the communities that have been hard-hit for too long.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Bibbins-Domingo K et al. JAMA Health Forum.

Corresponding Author: Kirsten Bibbins-Domingo, MD, PhD, MAS, University of California, San Francisco, PO Box 1364, San Francisco, CA 94143 (kirsten.bibbins-domingo@ucsf.edu).

Conflict of Interest Disclosures: Dr Havlir reported receiving nonfinancial support from Abbott. No other disclosures were reported.

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    2 Comments for this article
    Federalism: our State and Protectorate Meso-Nations
    Paul Nelson, MS MD | Family Health Care PC retired
    Ten years ago, Colin Woodard published his book American Nations (1). The book describes the original immigration patterns that underlie the cultural character of each state. The associated impact of forced emigration for native Americans and forced immigration for African Americans is acknowledged. The book serves to remind us that population health amidst our nation's republic government is based on local communities, neighborhood by neighborhood.
    When we speak of a strategic plan for a national immunization campaign, I propose four criteria as a means to adapt the process for locally occurring community circumstances. The program and vaccine should be />
    *) Equitably Available
    *) Ethnographically Accessible
    *) Justly Efficient, and
    *) Reliably Effective.

    Resolving our nation's diminished social cohesion, social mobility, and social isolation should be the norm for every community's safety net and its master disaster preparedness plan.


    1. Colin Woodard 2011. AMERICAN NATIONS A History of the Eleven Rival Regional Cultures of North America. New York,NY; Penguin Books.
    Great strategy - Look at how Alaska has done what you suggest
    Jane Ward, MD, MPH | Uniformed Services University
    Alaska has led the nation in percent of population vaccinated for several weeks. They have done this by doing many of the strategies that you outline in your discussion- including taking vaccine to far-flung native Alaska villages by plane or dog-sled if necessary and vaccinating entire households of groups at high risk.


    Thanks for sharing your wise insight!