The vaccine rollout was meant to prioritize
vulnerable communities, but four months of data shows healthier — and
often wealthier — counties have been faster to vaccinate.
As the U.S. rushes to
vaccinate its population against the coronavirus, most counties with the
sickest residents are lagging behind and making only incremental
progress reaching their most vulnerable populations.
A ProPublica analysis of
county data maintained by the U.S. Centers for Disease Control and
Prevention shows that early attempts to prioritize people with chronic
illnesses like heart disease, diabetes and obesity have faltered. At the
same time, healthier — and often wealthier — counties moved faster in
vaccinating residents, especially those 65 and older. (Seniors are a
more reliable measure of vaccination progress than younger adults, who
are less likely to have been eligible long enough to receive their
second shots.) Counties with high levels of chronic illnesses or
“comorbidities” had, on average, immunized 57% of their seniors by April
25, compared to 65% of seniors in counties with the lowest comorbidity
risk.
A similar gap has also
opened for all other adults. The one-third of counties with the highest
chronic illness risk have on average finished shots for 15% of their
64-and-under residents, four percentage points below the average for the
healthiest one-third of counties.
In counties with high rates
of chronic disease, residents are more likely to die prematurely from
heart or pulmonary diseases, diabetes or illnesses related to smoking or
obesity. Those conditions also increase a person’s risk of developing
severe COVID-19.
People with chronic illnesses are especially important to vaccinate
because their coronavirus infections are more likely to end in
hospitalization and death, said Janet Baseman, an epidemiology professor
at the University of Washington. If counties with high comorbidities
remain behind, she said, “then we are not accomplishing our objective,
as communities or as a nation, of saving lives.”
n the four months since
public vaccinations began, clear disparities have emerged in how quickly
the richest and poorest counties have delivered shots to their
residents. Multiple health experts and officials say the numbers
underscore a key strategic misstep under the Trump administration, which
asked state and local governments to prioritize people with illnesses
that would increase their chances of hospitalization or death, but
provided no additional funding to support the efforts.
Many states chose a
simpler approach, opening vaccine appointments to everyone 65 and older
with minimal on-the-ground outreach to people with chronic illnesses.
“It made some states go a little bit faster,” said Dr. Grace Lee, a
member of the CDC’s Advisory Committee on Immunization Practices and an
infectious diseases physician at Stanford Children’s Health. “But I
think it really increased the inequities early on.”
When vaccinations started
in December and January for the general population, the federal
Department of Health and Human Services distributed free doses and
supplies, but almost no money or staffing to administer the shots. State
and local health officials had to decide who would first be eligible
for the small amounts of vaccine then available and how to get doses
into arms. They also had to watch for interlopers — many of them young,
white and from other locations — who booked appointments they didn’t
qualify for.
In counties with more
chronic illness, identifying the neighborhoods and housing complexes
where residents or critical workers most need the shots — and then
actually getting them to accept vaccinations — can be complicated,
time-consuming work. Health officials in several counties with high
rates of chronic illness said they are making slow progress by focusing
resources on small events and mobile teams instead of on sprawling mass
vaccination sites.
ProPublica focused on
comorbidities because they are directly related to increased risk of
developing severe COVID-19. People with lower incomes are more likely to
have comorbidities; urban counties with high average incomes tend to
have fully immunized a larger share of their older residents than other
counties. In addition to income, the analysis looked at the urban and
rural divide, age demographics and differences between states’ overall
vaccination rates.
While communities of color
have disproportionately high rates of chronic illness nationally, the
analysis found no relationship between counties’ racial demographics and
coronavirus vaccination rates.
The rollout has largely
relied less on government outreach than on individual initiative. People
with flexible schedules, transportation and regular access to the
health care system have been better able to get appointments on their
own or with help from family and friends. Those with less support have
fallen behind.
Separately, surveys by the CDC
last year indicated that adults with underlying medical conditions were
less interested in getting the vaccine than healthier adults. People
surveyed who said they were unlikely to get vaccinated most often cited
concerns about side effects and safety.
To date, more than 98
million people in the U.S. — including 37 million seniors — are fully
vaccinated against the coronavirus, while another 150 million adults
have yet to receive a shot. During an address to a joint session of
Congress on Wednesday, President Joe Biden heralded the vaccination
effort as “one of the greatest logistical achievements” in the country’s
history.
The push continues even as
demand for shots appears to be declining, said Michael Osterholm,
director of the Center for Infectious Disease Research and Policy at the
University of Minnesota.
Providers injected more
than 21.7 million doses during the second week of April, according to
CDC data, as the supply of vaccines from Pfizer, Moderna and Johnson
& Johnson increased significantly. That number declined to 19.2
million shots the next week, and preliminary figures indicate
immunizations dropped even more sharply last week. (Federal authorities
temporarily paused use of the Johnson & Johnson vaccine for 10 days
to study a small number of blood clot cases potentially related to the
shot. It has since been cleared for use.)
There probably aren’t yet
enough fully vaccinated people in the U.S. to protect against another
surge, Osterholm said, especially with the more transmissible
coronavirus variants now prevalent. In Michigan, new cases again soared
in April, setting records for daily COVID-19 hospitalizations.
“We’re not out of the
woods yet in this country,” Osterholm said. “What happened in Michigan
could still happen in a number of other states out there. Even with the
level of vaccination they’ve had and the previous infections, look what
still happened.”
Reaching the most vulnerable has been a top concern for many of the poorest cities and counties since vaccinations began.
In Baltimore, COVID-19
caused far more severe illness and death in the majority-Black city’s
communities of color, where people with chronic illnesses are more
common, according to Dr. Letitia Dzirasa, the city health commissioner.
During the first month of the vaccine rollout, the Baltimore health
department realized it needed different tactics for immunizing its
seniors.
The city of Baltimore has
the highest rates of diabetes, smoking and obesity of the seven counties
in its metro area, and its premature death rate is nearly double that
of its neighboring counties, data from the National Institute of
Environmental Health Sciences shows. It ranks among the nation’s most
at-risk jurisdictions from chronic illness. Other parts of the region,
like the more affluent nearby Howard County, are among the healthiest.
CDC data shows just 55% of
Baltimore City’s seniors were fully vaccinated as of April 25, 15
percentage points lower than the rate for residents 65 and older in
larger Baltimore County, which surrounds the city.
Within Baltimore, Dzirasa said, the pandemic hit hardest in Black
neighborhoods on the city’s east and west sides, where residents have
long struggled against discrimination, poverty and chronic illnesses.
“Unfortunately, we’ve seen the same thing again with vaccination rates,”
she said.
The city health department
knew that many of its most vulnerable seniors would have no
transportation to vaccination sites, and that their senior living
centers were less likely than facilities in wealthier communities to
have relationships with pharmacies to secure doses.
In January, Dzirasa said,
her staff partnered with hospitals and pharmacies to create mobile
vaccine teams that could deliver shots directly to those most at risk of
severe COVID-19.
The first step was to win
residents’ trust with visits to centers from community health workers,
who explained the vaccines, provided reassurance and scheduled
appointments. The teams identified 117 senior living centers and have
immunized residents one by one at almost every facility over the past
three months.
“It’s definitely a slower approach,” Dzirasa said. “At these events, we’re doing anywhere from 75 to 150 people, tops.”
Baltimore has multiple
mass vaccination sites that can each provide from hundreds to thousands
of shots a day. A couple of months ago, all site appointments were
booked, and ineligible people had to be weeded out, Dzirasa said. Now,
those spots are increasingly unfilled, and Dzirasa expects gradual
progress going forward.
The disparity in
vaccination rates between counties with high rates of chronic illness
and the rest of the country is partly the result of the Trump
administration’s decision not to invest federal dollars in vaccine sites
at the beginning, argues Lee.
“They launched this
massive campaign and were like, ‘Good luck, you’re on your own,’” Lee
said. “And not only do you have to deliver a very complicated series of
vaccines, but on top of that we expect you to address inequities, all
without any additional support.”
The Biden administration
set up several mass vaccination sites in high-risk communities in
February and has now sent federal workers, equipment or funds to operate
more than 400 vaccination sites nationwide. But many counties with high
rates of comorbidity are still working to make up for a slow start.
The winter COVID-19 surge
was peaking when vaccine doses started to arrive in Wyandotte County,
part of Kansas City’s urban core. Small deliveries containing about
2,000 doses arrived each week from the federal government, said Dr. Erin
Corriveau, the county’s deputy medical officer.
At first, only health care
workers and nursing home residents qualified to be vaccinated. Then, on
Jan. 21, Kansas Gov. Laura Kelly opened eligibility to everyone 65 and
older, including more than 20,000 seniors in Wyandotte County.
“We’re going, ‘Oh my God,
that’s a huge number of people,’” Corriveau recalled. The county decided
to set its own eligibility rules, since it was still receiving just
2,000 doses a week.
Most new COVID-19 cases at
the time were young adults. To help drive down case numbers, Corriveau
said, the county temporarily narrowed eligibility to just residents 85
and older while adding critical workers whose jobs exposed them to
greater infection risk.
Wyandotte County opened
the shots to all seniors a few weeks later as case numbers dropped. But
the demand for shots was modest, Corriveau said, especially compared to
the clamor in other parts of the country, where older Americans
struggled to find providers with available doses.
The county now runs three
mass vaccination sites located on bus routes, with assistance from the
Federal Emergency Management Agency. It keeps pharmacies stocked with
vaccines, and dispatches “drop teams” to administer shots at small
neighborhood operations. Doses are plentiful, but willing recipients are
scarce. Corriveau said many of the county’s seniors are wary about the
vaccines’ safety and have been unwilling to get the shots at large,
impersonal sites.
“We’ve tried to make this
vaccine as available as humanly possible,” she said. “We’re
incentivizing vaccines with giveaways and food boxes and we’re doing
Saturday hours and expanding our evening hours.”
Despite those efforts,
only 56% of seniors in Wyandotte County were fully vaccinated as of
April 25. A few miles south, in Johnson County, more than 83% were
immunized.
The neighboring
jurisdictions have little in common with each other. Wyandotte,
meanwhile, stands out as being more diverse, with residents who suffer
from far more chronic illness. Wyandotte’s rate of premature death is
double Johnson’s rate, according to NIH data.
Tami Gurley, associate
professor of population health at the University of Kansas Medical
Center, said Johnson County has longstanding advantages that likely
helped its residents get vaccinated so quickly.
“You have people with
time, who can get on computers and sign up for multiple lists,” Gurley
said. “They all have their own transportation, nobody’s relying on
public transportation, it’s all private cars out here.”
The university medical
center where Gurley works is located in Wyandotte and cares for its
residents, she said. But many of its health workers live in other parts
of Kansas City, including Johnson County. “That is where the doctors
live, and the professors, and the people who tend to be more pro-vaccine
to start with,” she said.
Wyandotte’s health
officials are trying to reassure residents that the shots are safe and
that communities of color can trust the county health department.
“Frankly, there have been major, major issues of trust,” Corriveau said
of residents’ view of local agencies, “which are warranted.”
She and her colleagues are
increasingly asking trusted community leaders to stand in for
epidemiologists. Throughout the pandemic, Rev. Tony Carter, Jr., senior
pastor of Salem Missionary Baptist Church, has encouraged his
congregation to test for the virus, follow health protocols and, in
recent months, get vaccinated.
Carter’s church
volunteered to host a Saturday neighborhood vaccine event on April 17,
and nearly 50 people signed up for appointments to get the Johnson &
Johnson shot. But several days before the event, federal authorities
paused use of that vaccine as they investigated six cases of serious
blood clots among the 6.8 million people who had received it. (The U.S.
resumed use of the Johnson & Johnson vaccine without limitations on
April 23.)
The county switched to
another vaccine, but half of the recipients canceled their appointments.
Carter reassured his congregants that the vaccine would offer a way of
eventually reuniting with family. About two dozen people kept their
appointments and received their first vaccine dose. “Most of those
people stayed because of their connection to the church,” he said.
ProPublica analyzed county-level vaccination data from the Centers
for Disease Control and Prevention, looking for disparities in
immunization between jurisdictions at high risk of severe COVID-19 and
those with comparatively lower risk.
ProPublica used the comorbidities measure from the National
Institutes of Environmental Health Sciences’s Pandemic Vulnerability
Index to classify counties’ level of chronic illness. The one-third of
counties with the lowest comorbidity values were categorized as "low
comorbidity" and the one-third with the highest comorbidity values as
"high comorbidity."
The analysis used data on counties’ per capita income and racial
demographics from the U.S. Census Bureau’s 2014-2018 American Community
Survey 5-year estimates and the National Center for Health Statistics'
Urban-Rural Classification Scheme to categorize counties as urban or
rural and to identify counties within metropolitan statistical areas.
The CDC only releases county data on completed vaccinations — people
who have received both shots of a two-dose series, or one shot of
Johnson & Johnson vaccine. The data does not include the number of
people with comorbidities who have completed vaccinations. ProPublica
focused its analysis on the 65 and older population because it has been
eligible longest. The completed vaccination rate for seniors is a more
reliable measure than for younger adults, which includes many people who
have not been eligible long enough to receive their second shot.
Further, seniors are more likely to have chronic illness and elevated
risk of severe COVID-19.
The CDC does not provide county-level data for Texas and Hawaii, and
ProPublica excluded Colorado, Georgia, New Mexico, Virginia, Vermont and
West Virginia from its analysis because more than a quarter of those
states’ immunization records were incomplete.
