RESUMO
BACKGROUNDEquity in vaccination coverage is a cornerstone to a successful public health response to COVID-19. To deepen understand of the extent to which vaccination coverage compared to initial strategies for equitable vaccination, we explore primary vaccine series and booster rollout over time and by race/ethnicity, social vulnerability, and geography. METHODS AND FINDINGSWe analyzed data from the Missouri State Department of Health and Senior Services on all COVID-19 vaccinations administered across 7 counties in the St. Louis region and 4 counties in the Kansas City Region. We compared rates of receiving the primary COVID-19 vaccine series and boosters relative to time, race/ethnicity, zip code-level social vulnerability index (SVI), vaccine location type, and COVID-19 disease burden. We adapted a well-established tool for measuring inequity--the Lorenz curve--to quantify inequities in COVID-19 vaccination relative to these key metrics. Between 12/15/2020 and 2/15/2022, 1,762,508 individuals completed the primary series and 871,896 had received a booster. During early phases of the primary series rollout, Black and Hispanic individuals from high SVI zip codes were vaccinated at less than half the rate of White individuals, but rates increased over time until they were higher than rates in White individuals after June 2021; Asian individuals maintained high levels of vaccination throughout. Increasing vaccination rates in Black and Hispanic communities corresponded with periods when more vaccinations were offered at small community-based sites such as pharmacies rather than larger health systems and mass vaccination sites. Using Lorenz curves, zip codes in the quartile with the lowest rates of primary series completion accounted for 19.3%, 18.1%, 10.8%, and 8.8% of vaccinations but represented 25% of either the total population, cases, deaths, or population-level SVI, respectively. When tracking Gini coefficients, these disparities were greatest earlier during rollout, but improvements were slow and modest and vaccine disparities remained across all metrics even after one year. Patterns of disparities for boosters were similar but often of much greater magnitude during rollout in Fall 2021. Study limitations include inherent limitations in vaccine registry dataset such as missing and misclassified race/ethnicity and zip code variables and potential changes in zip code population sizes since census enumeration. CONCLUSIONSRacial inequity in the initial COVID-19 vaccination and booster rollout in two large U.S. metropolitan areas were apparent across racial/ethnic communities, across levels of social vulnerability, over time, and across types of vaccination administration sites. Disparities in receipt of the primary vaccine series attenuated over time during a period in which sites of vaccination administration diversified, but were recapitulated during booster rollout. These findings highlight how public health strategies from the outset must directly target these deeply embedded structural and systemic determinants of disparities and track equity metrics over time to avoid perpetuating inequities in health care access. AUTHOR SUMMARYO_ST_ABSWhy Was This Study Done?C_ST_ABSO_LIEquitable vaccine strategies are critical for the public health response to COVID-19, but there is limited understanding of how vaccination campaigns compared to different metrics for equity. C_LIO_LIMany initial approaches to vaccine allocation sought to acknowledge the known disparities in exposure risk, disease burden, needs, and access by formally considering social vulnerability or race/ethnicity in plans to prioritize vaccinations, but there is limited empirical evaluation of how actual primary vaccine series and subsequent booster efforts aligned with the initial goals set out for equity. C_LIO_LIWe quantify COVID-19 vaccine-related inequities in receipt of the primary vaccine series and booster across key equity metrics including race/ethnicity, social vulnerability, location, and time using a novel application of Lorenz curves and Gini coefficients--tools from economics to measure inequalities--in the St. Louis and Kansas City regions of Missouri. C_LI What Did the Researchers Do and Find?O_LIWe analyzed data from the Missouri State Department of Health and Senior Services on all COVID-19 vaccinations administered in the St. Louis region and Kansas City Regions. We compared rates of receiving the primary COVID-19 vaccine series and boosters relative to time, race/ethnicity, zip code-level social vulnerability index (SVI), vaccine location type, and COVID-19 disease burden. We adapted Lorenz curves and Gini coefficients to quantify the inequities in COVID-19 vaccination relative to these key metrics and examined how they changed over time. C_LIO_LIBlack and Hispanic individuals from high SVI zip codes completed the primary series at less than half the rate of White individuals during early phases of the primary series rollout, but surpassed rates in White individuals after June 2021. These relative increases in primary series completion rates in Black and Hispanic communities corresponded to periods when vaccinations became more available at small community-based sites. C_LIO_LILorenz curves demonstrated that zip codes in the quartile with the lowest rates of primary series completion accounted for 19.3%, 18.1%, 10.8%, and 8.8% of vaccinations but represented 25% of either the total population, cases, deaths, or population-level SVI, respectively. Tracking Gini coefficients over time demonstrated that these disparities were greatest earlier during rollout, but only improved slowly and modestly over time. C_LIO_LIPatterns of disparities for boosters were similar but often of much greater magnitude that those seen with completion of the primary vaccine series. patterns of disparities were similar but often of greater magnitude during booster rollout in Fall 2021. C_LI What Do These Findings Mean?O_LIVaccination coverage for both the primary series and boosters demonstrated substantial disparities across race/ethnicity, levels of social vulnerability, types of vaccine administration sites, and over time. C_LIO_LIDespite well-documented inequities for COVID-19 and need for equitable vaccine approaches, the strategies employed did not overcome deeply entrenched systemic inequities in health care and society. C_LIO_LIPublic health strategies must proactively target these deeply embedded structural determinants of disparities from the outset and should systematically track equity metrics over time to avoid perpetuating inequities in health care access. C_LI
RESUMO
The COVID-19 vaccination campaign in the US has been immensely successful in vaccinating those who are receptive, further increases in vaccination rates however will require more innovative approaches to reach those who remain hesitant, deliberative or indifferent. Phenomena such empty mass vaccination sites and wasted vaccine doses in some regions suggest that in addition to dispelling misinformation and building trust, developing more person-centered vaccination strategies, that are modelled on what people want could further increase uptake. To inform vaccine distribution strategies that are aligned with public preferences for COVID-19 vaccination campaign features we conducted a survey and discrete choice experiment among a representative sample of 2,895 people in the US, between March 15 and March 22, 2021. We found that on average the public prioritized ease, preferring single to two dose vaccinations, vaccinating once rather than annually and reduced waiting times at vaccination sites - for some these were the primary preference drivers. Vaccine enforcement reduced overall vaccine acceptance, with a trend of increasing control aversion with increasing vaccine hesitancy, particularly among those who were young, Black/African American or Republican. These data suggest that making vaccination easy and promoting autonomy by offering the public choices of vaccination brands and locations may increase uptake, and that vaccine mandates could compromise autonomy and increase control aversion in those who are hesitant - reducing vaccination in such groups and potentially undermining the goals of COVID-19 vaccination campaigns. SignificanceDCEs are a novel tool in public health that allow examination of preferences for a product, service or policy, identifying how the public prioritizes personal risks and cost in relation to health behaviors. Using this method to establish preferences for COVID-19 vaccination campaign strategies, our results suggest that: firstly, vaccination should be made as easy as possible for the public, second, that individuals should be offered choices of vaccine brand and vaccination location, and third, that vaccine enforcement could activate control aversion in the public and particularly in those who are most hesitant - potentially causing these groups to double down on vaccine resistance, a scenario which would impede the success of vaccination programs in the US.
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Policies to promote social distancing can minimize COVID-19 transmission, but come with substantial social and economic costs. Quantifying relative preferences of the public for such practices can inform policy prioritization and optimize uptake. We used a discrete choice experiment (DCE) to quantify relative "utilities" (preferences) for five COVID-19 pandemic social distances strategies (e.g., closure of restaurants, restriction of large gatherings) against the hypothetical risk of acquiring COVID-19 and anticipated income loss. The survey was distributed in Missouri in May-June, 2020. We applied inverse probability sampling weights to mixed logit and latent class models to generate mean preferences and identify preference classes. Overall (n=2,428), the strongest preference was for the prohibition of large gatherings, followed by preferences to keep outdoor venues, schools, and social and lifestyle venues open, 75% of the population showing probable support for a strategy that prohibited large gatherings and closed lifestyle and social venues. Latent class analysis, however revealed four preference sub-groups in the population - "risk eliminators", "risk balancers", "altruistic" and "risk takers", with men twice as likely as women to belong to the risk-taking group. In this setting, public health policies which as a first phase prohibit large gatherings, as well as close social and lifestyle venues may be acceptable and adhered to by the public. In addition, policy messages that address preference heterogeneity, for example by targeting public health messages at men, could improve adherence to social distancing measures and prevent further COVID-19 transmission prior to vaccine distribution and in the event of future pandemics. Significance StatementPreferences drive behavior - DCEs are a novel tool in public health that allow examination of preferences for a product, service or policy, identifying how the public prioritizes personal risks and cost in relation to health behaviors. Using this method to establish preferences for COVID-19 mitigation strategies, our results suggest that, firstly, a tiered approach to non-essential business closures where large gatherings are prohibited and social and lifestyle venues are closed as a first phase, would be well aligned with population preferences and may be supported by the public, while school and outdoor venue closures may require more consideration prior to a second phase of restrictions. And secondly, that important distinct preference phenotypes - that are not captured by sociodemographic (e.g., age, sex, race) characteristics - exist, and therefore that messaging should be target at such subgroups to enhance adherence to prevention efforts.
