Lack of equity within priority groups leaves Covid-19’s most vulnerable without vaccine, analysis suggests

As demand for Covid-19 vaccines continues to outpace supply, there’s still not sufficient supply to cover everyone within even the top priority groups. But by targeting vaccine distribution to more specific vulnerable populations, states could have the opportunity to save thousands of lives and prevent even more hospitalizations, according to a new analysis.

Around the United States, there are various plans in place to prioritize distribution of the limited supply of vaccines — in December, US Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices issued federal guidance about who should be first in line to receive the shots, starting with frontline health care workers and nursing home residents and staff, followed by other frontline essential workers and those age 75 and older.

But the total number of doses delivered across the country — more than 88 million — is barely enough to cover individuals in those groups with one shot, let alone the required second dose.

And ultimately, states decide who is first in line to receive a vaccine.

Health care data science firm Cogitativo analyzed thousands of health insurance claims and local demographics in California to assess the most predictive and discriminative factors leading to poor outcomes following Covid-19 infection.

By assessing known clinical risk factors, such as obesity, along with measures of the health effects of lived environment factors, such as air quality and access to fresh food, within the federal vaccination priority group recommendations, the company was able to more precisely pinpoint the most vulnerable individuals in the state and the counties where they live.

According to the analysis, dozens of counties in California would lack sufficient doses to serve the most vulnerable people in the state under federal guidance alone. Los Angeles County, for example, would have a deficit of nearly 405,000 doses.

Expanding those findings to the 10 largest states shows that about a third of counties would be lacking doses relative to the number of most vulnerable residents — and about 5 million doses could make a deeper impact in the fight against Covid-19 if reallocated to a different county.

“Without a surgical approach to distributing the vaccine, more Americans — often in communities of color and rural areas — risk being left behind,” Cogitativo CEO Gary Velasquez told CNN. “The key is to use a combination of real clinical data and social determinants of health to surgically assess who is at greatest risk. This approach can help states avoid acute deficits in certain counties.”

Equity in vaccine distribution

Experts CNN spoke with agreed that allocations should be more nuanced than the share of the population that falls within a certain priority group. For example, not all people over the age of 65 face the same level of risk from Covid-19, although a county with more people in that age group might receive more vaccines.

“The quickest and most rapid approach to saving the most lives and ultimately ending this pandemic sooner and faster has to intersect with understanding the conditions in which people are living, working, being educated and more,” Dr. Kedar Mate, president of the Institute for Healthcare Improvement told CNN. Mate was not involved in the Cogitativo analysis. “Social determinants of health have a very significant effect on the trajectory of this pandemic.”

Equity is central to the Biden administration’s plan to distribute vaccines through federally qualified health centers and FEMA sites, and dozens of states have adapted the federal framework for their own distribution plans, many specifically adding elements of equity into the equation.

But it has been a nationwide struggle to get it right.

In the coming weeks, California specifically plans to revamp its vaccine allocation plan to address concerns about equity in the rollout.

Currently, California allocates doses to local health departments proportionately based on their share of the state’s eligible population. Along with health care personnel, the state has expanded prioritization to all people who are at least 65-years-old, so a county with twice as many people in that age category than another would receive twice as many doses.

A new formula would allocate doses directly to providers in an attempt to bring coverage to neighborhoods that need it most. The goal is to reach disproportionately affected communities that the current system is not adequately reaching, Darrel Ng, senior communications adviser for the state’s vaccine task force told CNN.

‘Hard to prescribe’ at a national level

Experts CNN spoke with said federal guidelines gave a good sense of how to get started with the vaccination process.

But, they said, adjustments can be made locally as more is learned along the way, particularly focusing on groups that are most susceptible to the virus and poor outcomes from it.

“It’s hard to prescribe that at a national level,” Mate told CNN. “Every state and every region has to do some customization based on local experience.

Local health departments are well-versed on pockets of at-risk populations in communities, as well as the vulnerabilities within themselves and their surroundings that put them at risk.

They’re “uniquely positioned to be the backbone behind equitable distribution,” Lori Tremmel Freeman, chief executive officer of the National Association of County and City Health Officials.

But some local leaders say that it’s tough to focus on equity when supply is so limited.

“Without more supply, and steady and predictable information about future supply levels, it is challenging to ensure that we can quickly and equitably vaccinate those most at risk,” a statement from Santa Clara County, California, officials said.

According to Cogitativo’s analysis of counties within the 10 largest states, Santa Clara has the third-largest deficit of vaccine doses within the 10 largest states. The analysis suggests the county could receive up to 175,000 more doses than it would under federal guidance alone, due to its relatively large vulnerable population at risk due poor social determinants of health.

“In a lot of cases, counties are getting too limited a supply to have a deeper strategy addressing equity,” Freeman said. “We’re hearing it all the time. Some counties are only getting 100 vaccine doses a week and doing their best to parse that out among the priority groups.”

Others say that making the case for even more specific prioritization can be tough — especially when demand so far outweighs supply — but it helps to remind people of a shared goal.

In Texas, the state government rejected a plan proposed by Dallas to prioritize vaccinating people within certain ZIP codes. Ultimately, the state and county worked together, and they were able to prioritize based on socioeconomic status and community case spread, but not for specified ZIP codes.

“Because of the very limited supply, we wanted to make the biggest impact with the precious amount we did have,” Dr. Philip Huang, director of Dallas County’s health department, told CNN.

And there is more targeted prioritization happening. Federal vaccination initiatives running in tandem with state plans can help get the vaccine to more people. Vaccination sites run by FEMA in Dallas target people living in the 17 ZIP codes that local leaders helped prioritize.

Still, Dallas receives only about 9,000 doses of Covid-19 vaccine each week. There are more than 650,000 people on the waiting list.

“You do the math. It’s going to take some time,” Huang said. “We all want everyone to get it as soon as possible. The better we’re able to show we’re reaching the people most at risk to suffer, the better we’ll reach that goal.”