The distribution of COVID-19 vaccines in the U.S. has been complicated and disorganized. Though individual institutions tasked with making allocation guidelines have put forth significant effort, the lack of publicly available and centralized vaccination plans has contributed to substantial inefficiencies and inequalities in distribution.
These widespread imbalances in allocation have negatively affected many at highest risk for COVID-19, including Black and Latino populations. Many hoped these inequities would improve once eligibility for vaccination expanded from Phase 1A (health care workers and long-term care residents) to Phase 1B (elders and essential workers, in most states). But this has not yet happened.
One factor potentially contributing to the deficiencies is a lack of transparency about how vaccines are being allocated at each site. Increased awareness about this process would give the general public an opportunity to advocate for improvement or flag possible issues and inequities.
Consider the case of firefighters. The Advisory Committee on Immunization Practices (ACIP), which established the federal COVID-19 vaccine allocation guidelines, placed firefighters at a lower priority than other health care workers, even though firefighters occasionally provide CPR and other medical care and have a high risk of COVID-19 infection. Because these allocation guidelines were announced publicly prior to implementation, firefighters and their supporters were able to advocate for change. Their efforts led some states to reprioritize firefighters into Phase 1A.
In contrast, many individual vaccine distribution sites adapted federal and state guidelines to create their own allocation policies without informing the public prior to implementation. This lack of transparency hampered the public's and health experts’ ability to call out allocation inequities at individual sites. In some instances, people only learned about the policies after the fact through social media. These omissions, no matter how inadvertent, have contributed to inequalities in vaccine allocation.
Although ACIP has stated that vaccine allocation “must be evidence based, clear, understandable, and publicly transparent,” many vaccination centers have followed these principles inconsistently, if at all. For example, it was not publicly known until weeks into the first phase that ACIP’s Phase 1A guidelines were being interpreted differently across distinct sites. Some centers chose to vaccinate students and researchers with no patient contact, while others chose to vaccinate only health care workers with direct patient contact, even excluding their own hospital leadership.
If people, including public health experts, had a chance to review and comment on Phase 1A protocols in advance, perhaps some of the confusion and seemingly haphazard (at best) and inequitable (at worst) distribution could have been avoided.
Vaccine allocation sites with more liberal interpretations of Phase 1A most likely did not have bad intentions. Instead, many believed their ability to provide vaccines might be taken away if they moved to Phase 1B prior to receiving state approval, and so they stretched Phase 1A guidelines as much as possible. Such decisions nevertheless contribute to the ongoing racial, ethnic, and geographic disparities in COVID-19 vaccination rates.
Had these allocation schemes been publicly available prior to implementation, outcry against the vaccination of staff and students with no patient exposure may have been enough to open up Phase 1B sooner. Thus, essential workers and elders at much higher risk of death from COVID-19 might have been vaccinated earlier.
Public input is essential in creating equitable allocation strategies for resources as scarce and critical as COVID-19 vaccines. Public advocacy has already helped improve vaccine allocation by prompting some vaccination centers to change from a first-come, first-served approach to a more equitable random allocation method.
Transparency is just the first step forward toward health equity. Significant disparities in vaccine allocation by race, ethnicity, and geography will continue to exist, if vaccine allocation protocols are not reevaluated and changed to prioritize people at highest risk of morbidity and mortality from COVID-19. Rather than remain complacent with existing policies or blame inequities on vaccine hesitancy, we should heed the advice of experts in public health and health equity.
A group of leaders in the area recently developed concrete recommendations to that end, including utilizing a weighted lottery system that prioritizes people at highest risk based on metrics such as hospitalization rates and social vulnerability. Transparency in COVID-19 vaccine allocation policies is also essential in determining whether recommendations like these are being incorporated appropriately. Without simple access to these protocols, the public's capacity to facilitate equitable distribution will remain limited.
How do you believe states and individual sites can promote equitable distribution of COVID-19 vaccines? Share your thoughts in the comment section below.
Dr. Gina Piscitello is an assistant professor of palliative medicine, hospital medicine, and ethics consultant at Rush University Medical Center and a public voices fellow in The OpEd Project. The views expressed in this commentary are her own. Her Twitter handle is @ginapiscitello.
