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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.
Prioritize vaccine distribution to zip codes that have been most severely affected by COVID-19 and that have high indexes of economic hardship.
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.
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).
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.
Corresponding Author: Howard Bauchner, MD, JAMA (email@example.com).
Published Online: January 29, 2021. doi:10.1001/jama.2021.1205
Conflict of Interest Disclosures: None reported.
Jean-Jacques M, Bauchner H. Vaccine Distribution—Equity Left Behind? JAMA. 2021;325(9):829–830. doi:10.1001/jama.2021.1205
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