COVID-19: Study highlights disparities in vaccination, infection risk

• Although marginalized communities have had the highest numbers of severe COVID-19 cases, these populations have had less access to vaccines.
• Now, Massachusetts researchers highlight structural racism in the state’s vaccination strategy.
• While vaccine access has greatly improved, vaccine hesitancy remains a formidable challenge to vaccine equity.

Researchers at Harvard University, Tufts University, and Brigham and Women’s Hospital — all three institutions based in Massachusetts — argue that COVID-19 vaccination priorities in the state are an example of institutional racism.

In their research letter, which appears in the JAMA Health Forum, they assert that “disparities in vaccine coverage highlight ongoing inequities in the approach to COVID-19 and imperil efforts to control the pandemic.”

Scott Dryden-Peterson, M.D., M.Sc., the study’s lead author, is an assistant professor of medicine at Harvard Medical School and an associate physician at Brigham and Women’s Hospital in Boston, MA.

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Following the example of HIV prevention efforts

Dr. Dryden-Peterson and his team analyzed SARS-CoV-2 testing and vaccination data from early 2020 to the middle of 2021.

The data was compiled anonymously from over 6.5 million individuals in 293 communities throughout Boston and Massachusetts.

The researchers created a vaccination-to-infection risk (VIR) ratio to assess how vaccinations aligned with the risk of SARS-CoV-2.

They took cues from a 2018 study covering a regimen for HIV prevention. In an interview with Medical News Today, Dr. Dryden-Peterson explained:

“We noticed that among our patients, those living and working in settings with increased COVID-19 risk were facing the largest challenges accessing vaccination, whereas those able to have lower risk were accessing easily. This paradox reminded us of our efforts to make HIV preventative therapy available.”

Assessing future infection risk

The researchers used each community’s cumulative confirmed SARS-CoV-2 infections as their best indicator of future infection risk.

They also used Lorenz curves to gauge equity in vaccine distributions. Variable predictors included the:

• proportion of population aged 65 years or older
• proportion of people identified as Black, Latinx, or both
• quartile of socioeconomic vulnerability
• community size

The study’s results

Dr. Dryden-Peterson and his co-authors observed 649,379 SARS-CoV-2 confirmed infections among 6,755,622 individuals. This total included 3,880,706 fully vaccinated people.

They reported, “Cumulative incidence of confirmed SARS-CoV-2 infection (minimum, 1.6%; maximum, 24.1%) and complete vaccination (minimum, 26.5%; maximum, 99.6%) varied considerably between communities.”

Communities with higher socioeconomic vulnerability correlated with lower VIR ratios. This indicated a disparity in vaccinations relative to infection risk.

Communities where more than 20% of the population identified as Black, Latinx, or both had lower vaccinations relative to infection risk. However, communities with higher proportions of seniors showed “improved community vaccine coverage.”

Additionally, communities with fewer than 7,500 residents also showed higher vaccine coverage.

The researchers estimated that 810,000 full vaccinations would need to go to underserved communities to achieve equity.

Results are ‘not unexpected’

The study’s authors state that their analysis indicated “structural disparity in vaccine distribution.”

They emphasize the fact that Massachusetts ignored recommended steps “to mitigate structural racism.” Instead, the state channeled vaccinations to mass vaccination sites and large hospital systems.

However, the team admits that their research does not “directly assess the mechanisms of disparity.”

Jason Hall is the managing director at Avalere Health, a leading healthcare think tank. He has been instrumental in developing United States and global policies and strategies to improve vaccine access.

In speaking with MNT, Hall remarked: “It’s not unexpected to see variations based on race or ethnicity and socioeconomic vulnerability with regards to vaccination coverage.”

Hall also pointed to data from the Kaiser Family Foundation and the Centers for Disease Control and Prevention (CDC) showing similar trends.

Vaccine access or vaccine hesitancy?

Did the lack of access to vaccines or vaccine hesitancy pose a greater hindrance to COVID-19 vaccine equity among minoritized groups? Dr. Dryden-Peterson answered this question during his interview:

“Our study did not directly examine this, but the Massachusetts experience suggests that access prevents vaccine hesitancy. In the few instances where vaccines were made available to high-risk communities early and by long-standing, trusted community organizations, uptake has been as high as in high-income towns.”

Olveen Carrasquillo, M.D, M.P.H., is the Chief of the Division of General Internal Medicine at the University of Miami’s Miller School of Medicine. He also heads Florida’s statewide component of the National Institute of Health’s Community Engagement Alliance Against COVID-19 program.

During an interview with MNT, Dr. Carrasquillo agreed that “minority communities were left out” of vaccination efforts in the early days of the pandemic. However, the doctor noted that the inequities are shrinking.

He also mentioned that some efforts understandably contributed to vaccination fears:

“Let’s say you want to reach out to uninsured, undocumented populations getting vaccinated. You don’t [want to] have people dressed in army fatigues.”

Fortunately, Dr. Carrasquillo said, changes in federal leadership earlier in 2021 have paved the way for greater vaccine access.

Countering misgivings and misinformation

Now, experts assert, the greatest challenge to vaccine equity stems from a persistent slew of misinformation.

Hall has found that the reasons for vaccine hesitancy among minoritized groups include:

• concerns about potential side effects
• distrust in the government regarding the vaccines’ safety and effectiveness
• a general distrust of vaccines
• fear of contracting SARS-CoV-2 from the vaccine

He stressed: “[T]here certainly remains much work to be done with addressing the myths and misperceptions that prevent many people from seeking vaccinations.”

Dr. Carrasquillo is working with community partners to counter anti-vax messages that have been “very culturally competent [and] very targeted to specific minority subgroups.”

Ultimately, the study maintains, disparities in vaccination coverage reflect structural inequities. The authors emphasize: “Our approach needs to match this rather than blaming groups for being suspicious of a system that has left them out.”

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