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January 29, 2021

Vaccine Distribution—Equity Left Behind?

Author Affiliations
  • 1Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Editor in Chief, JAMA
JAMA. 2021;325(9):829-830. doi:10.1001/jama.2021.1205

Over the past 2 weeks numerous states have announced a major shift in coronavirus disease 2019 (COVID-19) vaccination programs—from a textured approach that includes individual risk factors for morbidity and mortality (eg, age and high-risk medical conditions), occupational risk factors for exposure (eg, first responders and correctional officers), and other societal priorities (eg, essential workers such as teachers, grocery store employees, and public transportation workers) to an approach focused on vaccinating all individuals aged 65 years and older. Concerns have been raised that the more detailed approach has been difficult to implement, thus slowing the rollout of vaccines, and may leave decisions regarding who gets vaccinated to people not adequately trained to make such a decision.

Prioritizing all individuals aged 65 and older in the US, about 55 million people,1 who account for approximately 80% of the deaths from COVID-19,2 seems straightforward and an effective way to reduce the number of deaths in the US. However, if this approach is adopted without explicit attention to promoting health equity, it will, once again, exacerbate major health disparities. Why? Because, in most cases thus far, the process of making an appointment to be vaccinated requires substantial time, technology, and trust—3 resources that are unequally distributed in much of the US population. A rapid digital connection, the time to repeatedly refresh the link to the appointment site or hold on the phone for hours, the ability to travel to a vaccination site, often by car, and trust in the safety and efficacy of the vaccine are factors that make it more likely for a person to seek and obtain a COVID-19 vaccine. Many people who have tried to sign up to receive a vaccine in the past week have found it time-consuming and frustrating, with few if any appointments available. At the same time, many people who are at highest risk for severe illness and death from COVID-19 have not yet sought out the vaccine due to lack of awareness, barriers to vaccine access, or concerns about the vaccine.

The health disparities laid bare by the COVID-19 pandemic have not been surprising in their direction. Likewise, the inequities that are likely to manifest when a limited supply of vaccine is rolled out to a large number of eligible individuals are predictable. As local communities roll out vaccine distribution to those aged 65 and older it is important to consider potential challenges and to proactively plan for ways to mitigate likely disparities.

  1. Prioritize vaccine distribution to zip codes that have been most severely affected by COVID-19 and that have high indexes of economic hardship.

  2. Partner with local health care institutions, community organizations, and other trusted sources to promote vaccine awareness and uptake within local communities, with particular attention to institutions and organizations that serve communities who have borne the brunt of COVID-19 exposure, illness, and death.

  3. Prioritize vaccine distribution to those who face mobility or other transportation barriers to receipt of the vaccine (eg, vans to deliver vaccine to homebound older persons, vaccination sites that are near public transportation, and hours of operation that are accessible to those who work or who rely on those who work during standard business hours).

  4. Simplify registration procedures. Ensure registration options that do not require the internet or digital platforms (such as phone or in-person registration). Ensure registration is accessible to those with limited English proficiency or limited literacy. Registration should not require nonessential documentation, such as proof of citizenship, that is likely to deter individuals from immigrant communities from seeking vaccination. Offer vaccination options that do not require preregistration (eg, at local community centers, schools, houses of worship, or other highly frequented and trusted sites in the community).

Many state and local health departments have already put much planning and resources into advancing the strategies outlined above. These efforts need to be further bolstered, not abandoned, in the push to get “shots into arms” as quickly as possible.

Communities should be able to generate daily and certainly weekly data to understand the demographics of who is being vaccinated. Local health departments and health institutions need to respond to these data in real time to identify where COVID-19 vaccine uptake is not matching COVID-19 disease burden. If disparities emerge, then additional targeted approaches to vaccine outreach, education, and administration, for example, house to house contact, may be necessary.

Throughout this pandemic there has not been enough attention to shared mission, shared vision, and shared sacrifice. The US should not shy away from the hard work and hard choices to do so with equity at the forefront. Vaccinating as many older individuals as possible is critical to reducing deaths from COVID-19. But, in the push to get as much vaccine administered as quickly as possible, the US cannot and must not leave equity behind.

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Article Information

Corresponding Author: Howard Bauchner, MD, JAMA (howard.bauchner@jamanetwork.org).

Published Online: January 29, 2021. doi:10.1001/jama.2021.1205

Conflict of Interest Disclosures: None reported.

Population Reference Bureau. Fact sheet: aging in the United States. Published July 15, 2019. Accessed January 27, 2021. https://www.prb.org/aging-unitedstates-fact-sheet/
COVID-19: older adults. CDC. Updated December 13, 2020. Accessed January 27, 2021. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html
12 Comments for this article
Fair and Equitable Vaccination
Kumar Swamy, MD | Retired from Medical Practice.
Dr. Howard Bauchner's narrative is right on target.

I would like to add there should be more involvement and cooperation from local municipal departments to make vaccination work, That would be a win-win program.
Age System Fair and Efficient
Richard Kuntz, J.D | Private
The distribution system is highly complex and problematic to date, but the age system is much simpler and largely conforms with the risk of serious outcomes and death. To attempt a reboot now is asking for a slowdown, as we race to keep up with new variants.
Vaccine Distribution—Equity Left Behind?
Paul Adams, BS JD | Private
Your suggestions however well intended are too complex and and will impede distribution resulting in more deaths. The death rate you admit is extremely skewed to the aged and that logically will save the largest number of lives, though not the ones you most value. "Equity" is subjective and personal.
Elizabeth Miller
Elizabeth Miller |
Equity in distribution of vaccines, which are in limited supply right now, doesn't just apply to the US but rather should be the guiding principle, globally speaking.

As the WHO DG Dr Tedros reminded us today, if countries horde vaccines and we don't share equitably, there will be three major problems

(1) it will be a moral catastrophe
(2) it keeps the pandemic burning and
(3) there will be a very slow global economic recovery.

Is that what we want? Let us make the right choice.

So vaccines are currently a limited
resource. If countries can vaccinate health workers and elderly populations and those with underlying health problems - around the world - then that is enough, for now. Let's have all countries have this now and then we can move forward with more broadly available vaccinations later.

We can end this pandemic through national unity and global solidarity and by understanding and accepting the notion that no one is safe until everyone is safe.
Vaccine Distribution
Charles Brill, MD - Retired | Thomas Jefferson University
Triage is an old, well-established medical concept. The issue is the appropriate criteria.

In our current Covid-19 situation the first to get vaccines should be medical workers and first responders, of all ranks.

Second should be essential workers.

Third should be all workers. These latter two categories would help care for the economy.

Last should be everyone else, including geezers, of which I am one.
Lottery Within Priority Strata
Paul Leber, MD | Neuro-Pharm Group
In the face of scarcity of a commodity, a lottery is the only fair means for its distribution. That said, some groups may reasonably be assigned a higher priority than others given their relative contribution to society as a whole.

A fair and sensible approach, accordingly, is to create strata based on societal needs and obligations, and to use a lottery within each stratum to rank the order in which vaccinations are made available to its members. (Admittedly, disputes are likely to emerge both as to which societal need or obligations should be designated as strata and
what the rank of each strata among all strata should be.

For example:

Strata 1: Health care workers having direct contact with Covid patients; substrata could be created to reflect the likely risk of infection based on the work done--medical staff directly involved in procedures like pulmonary aspiration would be granted higher ranking than a pediatrician working in a newborn unit.
Strata 2: First Responders, Firefighters, Police, EMT's etc.
Strata 3: Workers (oldest to youngest) providing critical services
Strata 4: All others based on their age, substrata based on strata at highest risk of death/morbidity/etc.

Race, religion, creed, national origin or economic status should NOT be used as a basis for ranking availability. Within any stratum, all are equal.
Michael Plunkett, MD, MBA | Practice
Since ancient times philosophers have taught us “the best is the enemy of the good.”

And it’s still true. Even California has chosen only age cohorts to qualify for vaccination. It’s just too complex to do it any other way.
Covid-19 Vaccine Equity
Murali Ramadurai, MD | Senior Healthcare Associates Inc.
The US has never vaccinated on a scale that Covid-19 has imposed.

The resources for public health and personnel have been decimated over several years due to budget cuts and lack of foresight for a potential pandemic.

Each state should have a central registration site that is user friendly to make an appointment and staffed with operators to help citizens to secure an appointment, or get back to them as vaccine supplies improve.

Operation Warp Speed produced vaccines but it is the vaccination that is the true story.

We need credible, competent leadership both at the
federal and state level to achieve universal vaccination that is efficient and timely.

I am still hopeful.
Equity Measures and Local Public Health
Michael Dohn, MD, MSc [Public Health] | Public Health - Dayton & Montgomery County (Ohio)
The interventions enumerated by Jean-Jacques and Bauchner are relatively easy to implement where public health has previously developed robust and ongoing relationships with minority communities. Public Health - Dayton & Montgomery County (Ohio) receives allotments of vaccine specifically for the elderly age cohorts. Of each allotment, Public Health designates 20% of those doses only for African American and minority individuals. We and community stakeholders (churches and others) arrange for vaccine clinics to serve the heavily affected African American and other minority populations in high incidence zip codes and economically depressed areas here. Stakeholders provide space for the clinics, promote messaging to the community, assist the elderly in scheduling vaccines, and help with transportation issues. Stakeholders are actively involved in planning the next phases of the vaccine rollout in their communities. Existing collaborative community engagement forms a foundation for actions to mitigate the effects of ongoing discrimination and institutional racism.
Time to get People Vaccinated
Kurtis Elward, Clinical Professor | Sentara Healthcare
I echo the several comments that the proposals in this article are laudable, but risk being far too complex to achieve the critical rate of vaccination that we need. There are certainly inequities to be recognized and dealt with. However, to proceed as the authors suggest could slow down vaccination rate for months. Indeed, many states' efforts have been delayed by several factors, including not only their understaffing and uncertain distribution, but also significant slowdowns in the process in part due to multiple albeit well-intentioned concerns about equity, which require re-tooling and re-orientation to respond to multiple entities claiming inequity (at one recent meeting there were over 20 different groups voicing their need, although few offered ways of helping this happen).

I would submit that this is the time to look at the task ahead of us and get as many people vaccinated as possible, all the while looking actively for gaps in the process but not slowing down aggressive vaccine efforts in the name of perfect justice. Indeed, the result will be gross injustice and continued inequities in COVID deaths.

I would agree with the authors that the ability to go online, and click through the multiple pages of confusing health department forms to get registered for the vaccine is beyond the capability of many of those at high risk. Many of my elderly patients, as well as some of my minority patients don't have a computer or reliable cell phone - yet that is what our public health website requires.

Much of this can, as the authors suggest, be addressed by having clinicians identify their at-risk patients, even simply by age, and linking these patients to health departments or local/state authorities to sign up, or being given allocations of the vaccine to be delivered at their clinics or having mobile clinics come to their office on specific days for those individuals (to name a few ideas).

It has been very frustrating for many of us in primary care to be largely ignored by health departments and other state entities, who must realize this is well beyond the capabilities of even the best health departments in the country and certainly traditional vaccination methods. Rather there must be far better collaboration with primary care groups as well as certain specialties that see very high-risk patients. That outreach has been minimal to nonexistent, despite calls by the AMA, and all the major primary care groups.

I do however completely reject the authors' unfounded and misguided claim that there has not been enough focus on shared mission, shared vision, and shared sacrifice. Tell that to the incredible staff at my practice, the innovative and selfless investment of time, energy and expertise at the front lines, and with the health departments that have had the greatest medical tsunami in history hit them. Tell that to the AMA members who kept their practices open at a loss for months, who could not pay their staff or had to close; to the tireless staff at the nursing facilities where COVID wreaked havoc - just to name a few.
Vaccine As a Public Good
Daniel Melnick, BA, MA, PhD | Retired Federal government
This article presents many insightful and useful questions and issues. We cannot succeed in defeating COVID if structural biases discourage under served people from vaccination. At the same time, we need to cover the whole population as efficiently and quickly as possible.

In that regard it is important to understand the vaccine as a tool for mitigating the effects of the virus, saving lives and rescuing our economy and society.

To do this, public policies need to focus on the vaccine and the institutions to administer it as a scarce public good that should be
mobilized for the greatest public impact.

A major problem with the effort so far has been a tendency to see vaccination as a problem of distribution rather than a tool to defeat the disease. We ask: who is most worthy of receiving it? Who is most in need?
A major problem with this approach is that vaccination is not merely for the benefit of the vaccinated. Rather it benefits all of us because as vaccination increases, the broader risk of disease is mitigated, the health care system is relieved of pressures and the economy, society and political system can recover from the broader effects of the disaster.

This implies:

 * Facilitating vaccination by simplifying how people register for and obtain the vaccine. We need to have systems that are accessible to people with limited resources but also use the internet to take the burden off of overtaxed and expensive in person assistance. The goal should be to have the people who can use the internet. This will allow those who cannot use the internet to reach a person to help them. The approach was very successfully used by the Census Bureau in the recently concluded population census.

* Using a wide variety of modes to administer the vaccine, but requiring individuals to register in only one place

* Allotting vaccine based on the risk of illness requiring medical intervention or death

* Using age and surveillance data for small areas as key criteria for staging the vaccination [This makes it possible to decide where to put the limited vaccination sites so the those in the highest risk group can easily reach them.]

* Establishing vaccine priority based on factors [such as employment exposures to the virus and age] that predict incidence, illness requiring medical intervention and death. The case data we have already compiled can be used for this

*Encouraging individuals to wait their turn by telling them where they stand in the queue

COVID is not merely the greatest public health challenge to our health care system in a century. It is also a serious threat to our society, way of life, and political system. Only concerted efforts targeted to this threat are appropriate and likely to succeed.
A Perfect Storm of Logistics, IT and Equity
Claude Gerstle, MD | Retired
I got my first Covid vaccination a month ago at Jackson Memorial Hospital in the heart of the Miami Black community. In the hour I was there I saw 2 African-Americans vaccinated, one of whom was my aide. A friend of mine had a similar experience there 2 days later. Unless you are dedicated and have lots of free time it's impossible to make an appointment. This is a major constraint in getting the working people, especially the poor, vaccinated.

What should be a quick procedure is bogged down in its own technology. And it is ancient technology. Demographic
information instead of being swiped off your ID card has to be typed in. Return appointment cards are hand written. At some sites the vial ID has to be handwritten. I don't know what happened to the self-stick labels. And then there is the consent form! I downloaded and signed a generic Covid permission. They could neither except that nor even scan it in. They insisted on going through the permission form and then have me do an online signature.

When I got my polio shot at school in the 1950s they just lined us up and shot shot shot. Is it that important to make sure we have an audit trail for the tort lawyers that we let it get in the way of speeding up the protection of our population?