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Pharmacies will be a critical venues for vaccine access, and this pharmacy distribution program is expected to build that capacity as the US Centers for Disease Control and Prevention (CDC) and state health directors work together to identity areas of need and ship vaccines to pharmacies in those areas, especially in the early days of the program when distribution is still curtailed by limited vaccine supplies. State officials told NASHP that the selection of pharmacies will be based on their ability to both reach the most vulnerable populations and also align with states’ current distribution phases and priority populations in their vaccination plans.

Tracking and Reporting Race and Ethnicity Data

One of the first steps to ensure equitable access to vaccines is having the data to determine where disparities exist. Forty-eight states and Washington, DC currently collect and share varying levels of vaccine data in publicly available data dashboards. Of these, 26 states and Washington, DC publicly display race and ethnicity data for individuals who have received their vaccines. States report the data slightly differently – which can result in different conclusions about their efforts. They are reporting either:

• Total number of individuals vaccinated by race and ethnicity (for example, Florida and Pennsylvania);
• Percentage of total individuals of each race or ethnicity in the state who have been vaccinated (North Dakota); or
• Percent of total doses that have gone to individuals by each race and ethnicity (Indiana and North Carolina).

While these state trackers provide some insight into who is getting vaccinated, there are limitations in their data – a large percentage of race and ethnicity data is either missing or not reported. Nationwide, race and ethnicity data is missing for nearly half of those vaccinated, compared to age and gender data, which is reported 99.9 and 97 percent of the time, respectively. Even in states that collect and publicly report this data, some report over 50 percent of doses with “unknown” race and ethnicity. Providers will report “unknown” in the race and ethnicity fields either because the providers do not ask for the data, or because the recipients do not provide it. It is unclear why individuals are declining to provide their race and ethnicity, but some experts believe that some concerns may stem from a fear that their demographic data could be misused. For example, immigrants are concerned that getting the vaccine – or providing their data – may negatively affect their immigration status. However, the CDC said that vaccine data cannot be used for immigration enforcement, and that getting the COVID-19 vaccine will not be considered as part of the public charge inadmissibility rule.

Many states are working to improve their data collection and reporting. Some, such as Alabama, are collecting race and ethnicity data but have not yet made it public because it is incomplete. These states are working to collect complete and accurate data before publishing it. Most states that are reporting race and ethnicity data publicly do not require providers to include that information, citing a lack of express permission from the patient or concern that requirements might prevent providers from reporting vaccine doses at all.

Other states are imposing requirements to improve data. In North Carolina, Department of Health and Human Services Secretary Mandy Cohen pushed to make race and ethnicity a required field in the state’s COVID-19 vaccine registry. According to state officials, North Carolina emphasizes equity as a core value and conducts outreach and training with providers to emphasize the importance of race and ethnicity data. The availability of the data has enabled outreach strategies, such as partnerships with faith leaders.

While requiring providers to upload race and ethnicity data can add to administrative and logistical challenges, collecting the data is critical to ensuring that vaccine outreach and administration are targeted to the communities most in need. If large percentages of race and ethnicity data are missing, ensuring equity in distribution becomes much more difficult.

Locating Clinics in High-Need Areas

Delivering vaccines to underserved communities is key and the new Federal Pharmacy Program helps address this goal. States and local health departments can use preliminary data to identify counties or jurisdictions with disparities and low rates of vaccination uptake to use to target their vaccination efforts.

Rick Palacio, the cochair of Colorado’s COVID-19 Vaccine Equity Taskforce, announced that one of the state’s goals is to hold pop-up vaccination clinics in half of the state’s top 50 census tracts containing low-density, low-income communities. Officials emphasized the importance of using data to determine under-vaccinated areas and tailor communication strategies to reach those residents. The state kicked off this plan by vaccinating more than 10,000 seniors at a mass vaccination event in Denver and plans to expand the initiative as it receives more doses.

Other examples of state efforts to identify and reach underserved areas include:

• Rhode Island is using its hospitalization, death, and case data to target vaccine distribution by geography. Vaccines will be available in community clinics, pharmacies, and housing sites in communities that have been identified as high risk.
• Illinois has had success by holding events scheduled by local health departments that reached out to discreet, hard-to-reach communities and invited them to register for a vaccine appointments.
• Connecticut is closely tracking vaccine rollout in localities that rank high on the social vulnerability index.
• After Washington, DC opened its vaccine registration portal to all individuals over the age of 65, data quickly showed that an outsized proportion of appointments was going to wealthier White residents. In response, health officials made more appointments available for residents in parts of the city that were currently securing the fewest vaccine appointments. The city also started making appointments for residents in these high-priority zip codes available a day before other eligible residents could register.
• North Carolina has partnered with faith leaders to ensure communities of color and underserved communities have access to vaccinations at the state’s mass vaccination clinics, including releasing appointments to Black and Latinx church attendees before opening up registration to the general public.

States can also reduce transportation barriers to increase vaccination uptake and ensure transportation will not be a barrier for targeted populations to access the vaccine. North Carolina’s mass vaccination clinic location was chosen for its proximity to public transportation.

The Tennessee Department of Health (TDH) is expanding access to the COVID-19 vaccine by focusing on increasing vaccinations in rural and underserved areas. TDH partnered with pharmacies and community health clinics to add over 100 vaccination sites across the state, focusing on “hard-to-reach” areas, as identified in the state’s vaccination plan. Tennessee’s state plan indicated that 5 percent of the state’s allocation of COVID-19 vaccines are earmarked for use in targeted areas with vulnerable populations.

Additionally, at a February US House Energy and Commerce Oversight and Investigations Subcommittee hearing, Louisiana state officials cited a plan to create community mobile strike teams that will travel to areas that rank high on the social vulnerability index to administer vaccines. The strike teams will be staffed by the National Guard and funded by the Federal Emergency Management Administration, which reimburses states for 100 percent of costs associated with the National Guard’s COVID-19 relief efforts. A state official in Michigan also noted at this hearing that the increase in doses from the federal government will help advance equity, because those extra doses can be distributed directly to underserved areas and minority populations.

Tailoring Communication Strategies to Address Vaccine Hesitancy

While reporting and tracking vaccination data and removing logistical barriers are important strategies for identifying pockets of need, they alone are not sufficient to reduce disparities. A history of racism in the health care system has led to distrust by communities of color. Though the share of adults planning to get the COVID-19 vaccine has increased over the year, according to recent surveys White adults (53 percent) remain more likely than Black (35 percent) and Latinx (42 percent) individuals to want to be vaccinated as soon as possible. A survey last fall found that less than 20 percent of Black Americans trusted vaccine safety and efficacy. The survey also indicated that the best messengers to support vaccination in these communities are those living in their own communities, or their health care providers.

State officials and several members of the federal Advisory Committee on Immunization Practices (ACIP) mentioned that the desire to vaccinate quickly must be balanced with the need to reach vulnerable communities. State officials note that balancing speed and equity is one of the biggest challenges they face. Community input builds trust and assists in building effective and acceptable strategies. For example, Tennessee has an African American Health Care Clinician Workgroup, with working members from the NAACP, the Black Nursing Society, and other Black organizations, who are disseminating messaging on the importance of vaccinations and will ultimately help vaccinate Black communities. The Colorado Department of Health and Environment has released commercials in English and Spanish featuring Colorado health care workers who are people of color, promoting the message that vaccines are safe. West Virginia is funding faith-based community members and people of color to administer COVID-19 vaccines directly to communities of color, ascribing to the principle that having trusted, local figures helping with distribution will improve those communities’ confidence in the vaccine.

Conclusion

Federal and state governments are working to vaccinate residents as quickly as possible, while also working to ensure doses are equitably distributed. In light of reports of disparities in vaccination rates and in vaccination access among people of color and in rural communities, the Biden Administration is acting on its promise to ensure an equitable distribution, including their new strategy to ship extra doses to pharmacies in hard to reach areas. While distribution strategies vary across states and are continually tweaked to improve efficacy and equity, the emerging best practices:

• Use data to track and identify under-vaccinated areas and populations;
• Set up additional clinics in underserved areas and provide additional doses to these clinics;
• Ensure transportation is available for patients to access the clinics; and
• Partner with local agencies and community organizations to promote vaccine confidence.

Each of these components is necessary to ensure underserved communities and communities of color are interested in receiving vaccines and are able to access them.