Coronavirus infection, hospitalization, and death have disproportionately burdened poor and minority communities. Our collective failure to direct interventions to these vulnerable populations has impaired the effectiveness of our national public health response. Consistent themes are evident across the country: Communities of color, often the poorest in the United States, face increased likelihood of exposure to the virus because of frontline essential work and often lack sufficient workplace protections. Transmission is accelerated in crowded housing, yet we have not consistently provided resources to permit those who are ill to effectively isolate. These challenges are compounded by inadequate access to both testing and optimal treatment. Structural racism and historical underinvestment in communities of color result in health and economic risks that exacerbate COVID-19’s most severe outcomes. We have fallen short of our most basic public health mandate to support the design, monitoring, evaluation, and tailoring of public health strategies that remove barriers to optimal care for our most vulnerable populations. As we scale-up distribution of COVID-19 vaccines, there is an urgent need to recommit to a more equitable pandemic response and prevent policy failures that may exacerbate health disparities. By establishing health equity metrics, rooted in place-based social vulnerability indices, the public health community can guide local vaccine allocation and provide a framework by which equity in allocation and implementation efforts will be measured. Metrics, when operationalized, can form the basis for equitable design, planning, implementation, monitoring, and evaluation of COVID-19 interventions.

Measuring Disparities Can Make Them Actionable

Metrics have guided our public health and clinical responses throughout the pandemic. Test positivity, incidence rate ratios, and hospitalization rates have allowed us to set community-level benchmarks for testing adequacy, hospital surge capacity, and mitigation and containment efforts. Beyond establishing clear targets, metrics acknowledge, name, and quantify systematic and often hard-to-describe gaps in the health care and public health response, and can mark substantive progress in eradicating those gaps. Metrics provide a vocabulary to articulate priorities and values, and create a shared language for stakeholder advocacy.

The California Department of Public Health, for example, has developed a health equity metric designed to ensure that each county’s unique disparities are measured and addressed as part of the county’s economic reopening efforts. This strategy, based on the California Healthy Places Index of social vulnerability and adapted as part of California’s Blueprint for a Safer Economy, mandates that counties can only reopen further if test positivity rates in a county’s most socially and economically vulnerable census tracts do not lag behind the county’s overall test positivity rate. The metric triggers state resources and technical assistance to develop equity-focused, county-level work plans to increase testing and reduce transmission in high-risk communities. The health equity metric has spurred stakeholder-generated, evidence-based programming to achieve pandemic control. The equity metric is also now a core component of California’s vaccine implementation strategy.

Equity Metrics Can And Should Inform Vaccine Allocation Strategies

Could a similar approach be applied to vaccine allocation and implementation nationally? The framework proposed by the National Academies of Sciences, Engineering, and Medicine acknowledges that disparities by race and ethnicity should factor into the prioritization of coronavirus vaccination. However, prioritization based on race/ethnicity is ethically and legally challenging, and potentially stigmatizing. The National Academies’ report recommends the use of place-based measures of social vulnerability, such as the Centers for Disease Control and Prevention’s Social Vulnerability Index or the COVID-19 Community Vulnerability Index, that include the racial, ethnic, and language composition of a census tract and capture key additional contributors to risk, including poverty, reliance on public transportation, and crowded housing. These known social and structural disparities are direct contributors to existing health care access and outcome disparities, and if not addressed, will serve as barriers to equitable vaccine allocation.

Benchmarking vaccine allocation strategies to a health equity metric will permit targeted distribution of this limited resource to marginalized groups within those already prioritized according to highest risk of transmission or poor COVID-19 outcomes. For example, most allocation plans prioritize residents and staff of long-term care facilities because nearly 40 percent of all deaths from COVID-19 in the United States have occurred in such settings. But even across these settings inequities abound, with recent evidence reporting that long-term care facilities with the highest proportion of Black or LatinX residents have disproportionately higher death rates. An equity metric would ensure that distribution to facilities that are located in vulnerable communities or that care for residents from those communities would receive prioritized vaccine allocation, especially if and when vaccine supply is limited. In each phase of distribution, an equity metric could be implemented locally either by prioritizing individuals based on address or situating distribution sites in the most vulnerable neighborhoods.

Equity Measures Keep Vaccination Programs Accountable To Underserved Communities

The Advisory Committee on Immunization Practices encourages integration of health equity into COVID-19 vaccine implementation plans. Specifically, vaccine implementation strategies should address social and structural barriers to vaccination among populations disproportionately affected by COVID-19, target known disparities, be conducive to “real-time” refinement, and mitigate any unintended negative effect on health care disparities.

How can we not only adopt an equity framework to guide allocation but also monitor programs based on equity metrics? Lessons learned from national initiatives to address childhood vaccination disparities are relevant. These programs, such as the Vaccines for Children Program, have long incorporated an equity focus based upon a framework that recognizes disparities based on social, economic, and racial/ethnic factors and which required that communities most affected by disparities met threshold metrics for immunization coverage. The success of these programs is rooted in a strategy that combines policies and resources to increase vaccinations in minority communities, real partnerships with community organizations, and ongoing monitoring and surveillance based on a priori equity metrics.

Would adding an explicit equity measure add further complexity to the already urgent distribution of COVID-19 vaccines? Yes—but the benefits outweigh the logistic intricacy for several reasons. First, this approach embraces equity and embeds it as a central feature of each element of our national vaccine strategy—from planning to distribution, and from messaging to uptake, and ultimately, our national public health response. The elements of an equity-focused vaccination strategy can be adapted to the fair allocation of novel COVID-19 therapeutics, as has already been implemented by some states, as well as applied to post-pandemic economic and health-related investments. Second, an equity framework would support the immediate immunization of communities with higher transmission rates and fewer resources to combat the pandemic, benefiting not only that community but all communities in our indisputably interconnected society. Third, an equity metric will hold us accountable through a pragmatic, non-stigmatizing strategy to address extant issues of vaccine hesitancy and health system distrust. By intentionally incorporating equity metrics within the COVID-19 pandemic response, our public health community has the opportunity to create an actionable paradigm that can be used to reduce disparities across diseases and across communities. This is an opportunity we cannot afford to squander.

Authors’ Note

The views and opinions expressed by the authors are their own and do not necessarily represent the views and opinions of the California Department of Public Health, the California Health and Human Services Agency, or the state of California administration. Thank you to Amy J. Markowitz for her review.

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