US COVID-19 Vaccine Distribution Disproportionate to Death Burden


A neighborhood-level assessment of major cities show areas impacted the most by historic COVID-19 deaths are significantly less vaccinated.

A new study of the 9 largest cities in the US show inequity in COVID-19 vaccination rates among the communities differently affected by the pandemic.

Namely, the JAMA Health Forum research letter findings show that vaccination has been disproportionately higher in communities that have experienced fewer deaths from COVID-19 leading up to vaccine distribution.

The assessment from Adam Sacarny, PhD, of the Columbia University Mailman School of Public Health and Jamie R. Daw, PhD, of the National Bureau of Economic Research, evidence another COVID-19 response that has been hindered by national health inequities: appropriate and evidenced distribution of emergency-authorized COVID-19 vaccines.

Sacarny and Daw used neighborhood-level data in their cross-sectional assessment of COVID-19 vaccination rate among differing US communities. Their estimation included the 9 largest cities in the country and their surrounding counties (save for Chicago, IL), constituting about 41 million Americans:

  • New York, NY
  • Los Angeles, CA
  • Chicago, IL
  • Houston, TX
  • Phoenix, AZ
  • Philadelphia, PA
  • San Antonio, TX
  • San Diego, CA
  • Dallas, TX

“The equitable receipt of COVID-19 vaccinations is a national priority,” investigators wrote. “Most jurisdictions in the United States report limited data on vaccinated people, impeding assessment of vaccination equity.”

The pair obtained COVID-19 vaccination and death rate data from these regions via health authority websites, and sociodemographic information—including vaccine recipients’ self-reported race and ethnicity—via the American Community Survey results.

Neighborhoods, as defined by zip codes, were divided into quartiles based on vaccination rate (adults to receive ≥1 dose). Sacarny and Daw then calculated the mean COVID-19 death rates and sociodemographic characteristics for each quartile.

The cumulative death rate from COVID-19 through April 13, 2021 was used to interpret each city’s historical burden of the pandemic virus, and the investigators conducted a concentration analysis to assess the share of vaccinations administered in neighborhoods with the greatest death rates. Their assessment included 1127 neighborhoods.

The observed neighborhoods had a mean COVID-19 vaccination rate of 42.3%—though there was a significant disparity between the lowest quartile (27.6%) and highest quartile (59.7%). Sacarny and Daw observed a greater share of White and Asian people, and a lower share of Black and Hispanic/Latino people in neighborhoods with high vaccination rates.

These neighborhoods also had greater mean income, lesser poverty rates, greater 4-year college completion rates, and greater rates of workers in health care or technology.

For every 25 fewer historical COVID-19 deaths per 100,000 population in a neighborhood, investigators observed a 10 percentage-point increase in its COVID-19 vaccination rate (P <.001). In fact, neighborhoods with the greatest vaccination rates, despite having more at-risk older adults, had the lowest rates of historical COVID-19 deaths.

Investigators observed 863 neighborhoods with COVID-19 death data. Of them, the 209 neighborhoods with the highest death rates accounted for approximately half of all historical COVID-19 deaths, but only one-fourth (26%) of all vaccinations.

Sacarny and Daw cited limitations including possible vaccination and death reporting inaccuracies, as well as the limited generalizability of the findings beyond the 9 major cities. However, the findings ultimately underscore the burden of health care access and education inequity that has driven the ongoing discriminate effects of COVID-19 in the US.

“Inequities in vaccination rates across neighborhoods likely reflect several root causes, including systematic underinvestment in public health in segregated communities, unequal access to health care information and services, and medical racism that drives legitimate mistrust among members of marginalized groups,” they concluded. “The findings of the present study emphasize the opportunity and need for cities to address vaccination inequities in marginalized communities.”

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