Assessment of Practices Affecting Racial and Ethnic COVID-19 Vaccination Equity in Ten Large US Cities

Lack of consistent public reporting and transparency of COVID-19 vaccination data has impeded the ability to track the effectiveness of strategies that target vaccine equity.

Systemic racism in health care still exists, evident in the disproportionate impact of the COVID-19 pandemic on Black and Hispanic populations. Racial and ethnic disparities in vaccine uptake have been attributed to mistrust of the medical system by historically marginalized communities and subsequent vaccine hesitancy. To combat these inequities, significant investment by public health officials in vaccine equity efforts and strategies is required.

As researchers under Dr. Mark Sendak, we sought to investigate the impact of vaccine equity efforts on vaccination rates in minority populations. I, Cole Honeycutt, previously worked with Dr. Sendak to address substantial language barriers that Latinx communities face when accessing health care at hospitals. I, Jackie Contento, volunteered at several urban and rural COVID-19 vaccination clinics and first-hand witnessed substantially fewer people of color receiving vaccines. Collaborating with researchers at the Duke Institute for Health Innovation provided us the opportunity to explore equitable COVID-19 vaccination policies to a greater extent.

Many states created COVID-19 vaccination plan proposals to ensure efficient and equitable distribution of vaccines during the initial rollout. However, we noticed that several promising practices to reduce racial and ethnic disparities were often overlooked in these initial proposals. Thus, we wanted to learn if the implementation of these best practices in ten selected cities impacted the vaccination rates in their underserved populations.

What We Found

Throughout our research, which compiled information between January and June 2021, we found it difficult to collect substantive vaccination data from several state public websites due to their varying methods of reporting. Although data transparency is essential for addressing vaccine distribution gaps and tailoring outreach efforts, we discovered that there was a high percentage of missing racial and ethnic information. Specifically, we learned:

  • Not all health departments categorized Hispanic as an ethnicity. Los Angeles, Chicago, Houston, Philadelphia, Phoenix, and Boston all considered Hispanic as a value within the same demographic category as White, Black, and Asian. This differs from the US Census Bureau, our source for population data, which assigns individuals to both race and ethnicity categories.
  • Vaccination data were further compromised in certain cities. For example, Florida stopped reporting demographic, by-county vaccination data on June 3, 2021, and instead transitioned to weekly updates for the state. Furthermore, Florida labeled Asians as “Other” instead of an Asian demographic category. For Chicago, only fully vaccinated data were reported, instead of reporting “at least one dose” vaccination data. On the other hand, Boston only reported “at least one dose” vaccination data. Both Philadelphia and Boston reported vaccination data as percentages of the current population, instead of individual counts.

Despite these findings, we also came to learn that cities were moving in the right direction as the pandemic continued: there was increased implementation of vaccination equity best practices in each US city. Even though few cities proposed these best practices in their initial vaccine distribution plans, they were able to adopt these strategies to ensure greater vaccine equity.

Overall, we concluded that COVID-19 vaccination reporting was profoundly heterogeneous across the United States throughout the vaccine rollout. These inconsistencies mirror those of other components of the often-fragmented US COVID-19 response, including public health guidelines, restrictions, and testing.

Moving Forward

Our study demonstrates the need for a more unified structure in public health response among states. The lack of consistent public reporting and transparency made it difficult for us to track whether and how certain vaccine equity strategies made a difference. For instance, variation in Hispanic categorization inhibited our ability to effectively assess whether vaccination equity programs were reaching Hispanic communities. Without this knowledge, cities could not realize pitfalls in their vaccination distribution plans and subsequently increase implementation of COVID-19 vaccination equity best practices. What can be done to help?

  1. Improved standardization and reporting of vaccination data. This may include common definitions of racial and ethnic groups across US states, inclusion of all common racial and ethnic groups, continuity of public vaccination data reporting over time, or creation of a federally operated centralized database.
  2. Widespread implementation of vaccination equity strategies. This may include increasing awareness of the disparities within healthcare, designing community-based solutions to target minority populations, and assigning public health officials roles to monitor the effectiveness of equity programs.

Want to learn more about what we found and the implications for public health? Read our paper here:

Christopher Cole Honeycutt is currently a post-baccalaureate research fellow at the National Institutes of Health Vaccine Research Center, where he studies the protective efficacy of and the immune responses elicited by COVID-19 vaccines against emerging viral variants. He graduated from Duke University with a Bachelor of Science in Biology in May 2021.

Jacqueline Contento is currently a biomedical engineer at Children’s National Hospital, where she designs new methods to implant pacemakers and reconstruct congenital heart defects in pediatric patients. She graduated from Duke University with a Bachelor of Science in Biomedical Engineering in May 2021.